Sometimes, basic treatments aren’t adequate for some types of headaches. That’s when advanced physical therapy approaches should be considered.
​
Although not all headaches are created equal, many are successfully treated in physical therapy. In the video that follows, Brent Dodge, PT, describes the characteristics of migraine headaches, tension and cluster headaches, and cervicogenic (originating in the neck) headaches. Specific types of physical therapy treatments used to abolish these headaches are detailed.

People who take steps to learn about their aches and pains tend to improve, faster. Knowledge is power, a huge first step toward healing an orthopedic ailment.

Shoulder pain? It doesn’t always spell a torn tendon and imminent surgery. In fact, most people we see in physical therapy for shoulder pain do quite well with the care of their doctor together with physical therapy treatment.

Learn all you can.

To help, we’ve created a Resource section on our website filled with information on over 200 orthopedic conditions, such as back pain, rotator cuff injuries, carpal tunnel syndrome, and arthritis. Go to Resources and click on “Conditions.”

You can also access our video library of hot topics in PT, orthopedics, health and wellness, and sports performance. In the Resource section, click on Health Information and go to AlpineTV.

Check out AlpinePTmissoula.com under “Resources.”
​
Get the facts in easy read format with some of the best anatomical artwork available today on the web, making learning about your condition meaningful and easy.

On one hand, the notion of pelvic pain may seem a bit “off topic.” On the other, if you have it, you’re not alone and you deserve answers.
​
Were you aware there are two specialized physical therapists in Missoula who offer help for this condition? Tara Mund and Morgan York-Singer, both Doctors of Physical Therapy at Alpine Physical Therapy, continue to help area women with a host of different conditions. They are compassionate and caring experts in the treatment of pelvic pain as well.

Here’s an excerpt from the Her Health webpages on the topic of pelvic pain.

**************

Pelvic pain can be described as an ache, burning or sharp discomfort located in the abdomen, pelvis, or perineal area.  It usually is present for greater than six months and may prevent or interrupt sexual intercourse and may make gynecologic pelvic exams uncomfortable.

Pelvic pain can be caused by several problems including muscular imbalances within the muscles of the pelvic floor, trunk or hips, pelvic joint dysfunction, tender points or trigger points located in the deep hip muscles or pelvic floor, pressure on nerves through the pelvis or dysfunction of the muscles related to bowel and bladder function.  It can also be attributed to the presence of scar tissue after pelvic or abdominal surgery.
​
Patients may describe pain through the pelvis, hip, back or tailbone including difficulty sitting or wearing tight clothing. Patients with pelvic pain may also experience disruptions in bowel or bladder habits such as frequent urination, incontinence, constipation, or straining with bowel movements.

Physical therapists are trained in the assessment and treatment of muscular imbalances, movement analysis, and joint dysfunction. They commonly treat impairments including joint restrictions or instability, muscular tightness and weakness, as well as motor control difficulties.  The Her Health physical therapists at Alpine have additional specialized training in the assessment and treatment of pelvic floor dysfunction.

A thorough examination is necessary to design an individualized plan of care for the patient suffering from pelvic pain.  Treatment may include manual techniques to address muscular restrictions as well as motor control and breathing strategies for relaxation. Targeted strengthening may be included to improve strength, muscular endurance, and correct faulty muscle recruitment patterns during the rehabilitation process.
​
For more information on the services available through Her Health at Alpine Physical Therapy, click here.

Special thanks to star physical therapist Antara Quiñones of Alpine Physical Therapy for providing this write up on a recent article from the Journal of American Academy of Orthopedic Surgery.
​
*************

Toes are like teeth- you take them for granted until they hurt and then you realize how much you rely on them and are amazed at how much pain they can cause.  Toe instability resulting in a rigid deformity is a common foot problem.  A recent review article speaks to new knowledge of toe instability and a surgical technique that should be utilized—specifically, repairing the plantar plate.

In a healthy foot the tiny muscles of the feet and toes along with ligaments on the sides of your toe joints (collateral ligaments) and a thick piece of fibrous tissue on the pad of your feet and toes, called the plantar plate, help to resist the forces your toes undergo during walking and running.  The second toe is most vulnerable to hyperextension because there is no muscle responsible for resisting your second toe moving towards your big toe. Authors of this review found that the plantar plate is primarily responsible for the stability at the 2nd toe joint.  If this plantar plate is torn, due to abuse or trauma, and not repaired the toe instability becomes worse and typically results in a crossed toe.

Toe deformities go by various names depending on the direction the toe goes, but generally speaking a bent toe is called “hammer toe” which can turn into a toe stuck under or over the adjacent toe.  Any deviation from a straight toe is an indication of joint instability and should be addressed to prevent future pain and walking difficulty.

Hammer toe is caused by outside pressure (like high heels), inflamed joints, and autoimmune diseases. Predisposing factors include genetics, a longer second toe, flat feet, and an already poorly aligned big toe.  Curled toes, or hammer toes, most often happen to women older than 50 years old whose feet have been pressed into high heeled shoes with narrow toe boxes.  Men and younger people can also develop hammer toe, however it is more rare.  Often, these deformities are ignored until they become “fixed” or the bones have fused into place. Fused toes are problematic because as we push off with our back foot while walking the toes must bend and tolerate 40% of our body weight.

Symptoms of toe instability are pain on the bottom of your toe where it meets your foot, toe swelling and numbness, a feeling of “walking on marbles,” and a gradual change in the direction of your toe towards encroaching on its neighbor.  It may be uncomfortable to walk barefoot or feel better to walk on the outsides of your feet. Imaging, such as x-rays or MRI, can diagnose hammer toe.  However two simple tests combined show good diagnosis results: a “drawer test” to test the mobility of the joint, and trying to pull a piece of paper out from under the toe in standing.

Treatment of hammer toe depends on the extent of the instability of the toe joints.  Often, people do not seek treatment until the toe has completely crossed under or over and has become rigid. Conservative treatment is moderately effective for early joint instability and includes shoe modification (lower high heels, wider toe box, more cushion), pads placed in the shoes or rocker bottom shoes to redirect the forces across the foot during walking, or steroid injections at the joint (keeping in mind that any steroid relieves pain but does disturb the already fraying tissues). Keeping your foot, ankle, and calf muscles strong can also help, as well as checking in with a physical therapist to help correct any faulty movement patterns further up the chain.

Surgery is a common option, especially for more advanced stages of hammer toe. Two main approaches are used–one accessing the area from the sole of the foot and the other from the top of the foot.  Surgeons trim any unhealthy tissues and suture any obvious tears in the plantar plate and collateral ligaments.

In the past the collateral ligaments have been the primary tissue repaired.  However, authors found better outcomes with surgery prioritizing plantar plate repair along with collateral ligament repair.  They found that this helped significantly with lasting deformity correction and improvement in pain and a person’s ability to function.

Jesse Doty, M.D. Metatarsophalangeal Joint Instability of the Lesser Toes and Plantar Plate Deficiency. In Journal of American Academy of Orthopedic Surgery. April 2014. Vol. 22., No 4. Pp235-245.
​
For more information, visit this topic module on our clinic website by clicking here.

Last weekend, several of Alpine’s physical therapists attended an excellent course here in Missoula on helping patients with persistent pain issues by way of mobilizing their nervous system. 

Brent Dodge, Gary Gales, Dennis McCrea, and Brace Hayden took a two day continuing education class designed to help people with chronic pain and irritable back, neck, and extremity issues move and feel better.

Re-educating the body that ‘movement is good medicine’ is a helpful approach for those in pain that avoid healthy mobility. The course was a thorough approach to assessing and treating this patient population with a lot of dynamic interventions to optimize their return to a higher level of activity. 

Here Gary Gales mobilizes the radial nerve path in the arm of our co-worker Dennis McCrea. 
​
For more information about the approach Alpine Physical Therapy takes to help people with persistent pain, visit our webpage describing our Pain Clinic by clicking here.

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.

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.
​
Reference:
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.

Special thanks to star physical therapist Antara Quiñones for providing this write up on a recent article from the Journal of Hand Surgery.

**************
​
Mallet finger typically occurs with “jamming your finger”, like hitting a basketball with a straight finger, forcing it to bend when not expected.  If the tendon that attaches near the base of your fingernail is unable to withstand this sudden force, it “avulses” or rips out of the bone creating a droopy fingertip.  Unless this tendon is reattached somehow, you will never be able to straighten the tip of your finger again. Typically, this does not interfere with your ability to do things.

People seek treatment because they are more concerned about how their finger looks.  A small percentage of mallet finger injuries can progress to a “swan neck deformity” where the tip of your finger is stuck pointing down and the middle knuckle is hyperextended in the opposite direction. This does interfere with finger function and treatment is typically necessary.

Treatment options for mallet finger vary depending on the length of time after injury that the droopy finger shows up (its not always immediate).  Treatment is deemed successful if there is little or no “extensor tendon lag,” meaning you are able to straighten your finger fully.

The most conservative treatment option is long term splinting.  This involves wearing a specially made finger brace that holds your finger in a neutral position in hopes that the tendon will reattach via scar tissue.  This can be anywhere from 6 to 14 weeks.  Most patients see acceptable success with splinting alone–their finger tip may be not quite straight but less noticeably bent–and do not seek further treatment.

Surgery is the next step if splinting does not work.  However, recent review of the literature suggests that despite many different applications of surgical procedures, results are relatively no better than splinting alone.

Authors of this literature review concluded that splinting should be the primary treatment for a mallet finger, especially if it has been longer than 4 weeks since the injury.  Their reasoning being that splinting is just as effective as surgery, a mallet finger typically does not interfere with day to day life, and is corrected typically for aesthetic purposes only.

Nina Suh, MD, Scott W. Wolfe, MD. Soft Tissue Mallet Finger Injuries With Delayed Treatment. In Journal of Hand Surgery. September, 2013. Vol 38A. Pp. 1803-1805.
​
For more information on this topic visit our clinic resource pages by clicking here.

The week of May 26th will be a short one at Alpine Physical Therapy. We honored Memorial Day on Monday May 26th, and  we will also be closed on Friday May 30th in order that our therapy team can participate in a local continuing education opportunity.

On May 30th and 31st our Alpine physical therapists will be attending the 6th Annual Montana Pain Initiative Conference in which the topic is “Treating Pain: Neuroplasticity and Team Care in an Evolving Healthcare System”.

Neuroplasticity is a really cool thing for those that suffer from chronic pain and disability. It means our brain changes constantly and with it opens up the opportunity for each day to be different and potentially better than the day before. The biggest reason we decided to close our clinics on such a short week is hinted at in the title as well, “Team Care”. We will be interacting with local physicians, psychologists, psychiatrists, pharmacologists, other rehab specialists that treat pain and learning better ways to communicate so we’re all speaking the same language.

This will help our patients in the long run. So we apologize to everyone for not being open but hope you’ll understand it is in the interest of quality care, which is our number one priority. We will be open for a few hours at each clinic in the morning for any scheduling needs or questions that can be answered by our support staff.
​
For more information on the conference click here. http://www.wmtahec.org.

The week of May 26th will be a short one at Alpine Physical Therapy. We will be honoring Memorial Day on Monday May 26th, and we will also be closed on Friday May 30th so our therapy team can participate in a local continuing education opportunity.

On May 30th and 31st our Alpine physical therapists will be attending the 6th Annual Montana Pain Initiative Conference in which the topic is “Treating Pain: Neuroplasticity and Team Care in an Evolving Healthcare System”.

Neuroplasticity is a really cool thing for those that suffer from chronic pain and disability. It means our brain changes constantly and with it opens up the opportunity for each day to be different and potentially better than the day before. The biggest reason we decided to close our clinics on such a short week is hinted at in the title as well, “Team Care”. We will be interacting with local physicians, psychologists, psychiatrists, pharmacologists, other rehab specialists that treat pain and learning better ways to communicate so we’re all speaking the same language.

This will help our patients in the long run. So we apologize to everyone for not being open but hope you’ll understand it is in the interest of quality care, which is our number one priority. We will be open for a few hours at each clinic in the morning for any scheduling needs or questions that can be answered by our support staff.
​
For more information on the conference click here. http://www.wmtahec.org.