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[Physio Discussed] Tackling tendinopathy: evidence, exercises, and everything in between with Dr Ebonie Rio & Dr Seth O’Neill

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In this episode, we discuss the management of lower limb tendinopathy. We explore: 

  • Current evidence based management of tendinopathy
  • Differential diagnosis of tendinopathy and peritenon
  • Role of compression in tendinopathy
  • Speed of exercises used in rehabilitation
  • Patient specificity for exercise prescription
  • Importance of load in rehabilitation
  • Role of inflammation in tendons

Dr Seth O’Neill has been teaching and researching at the University of Leicester since 2006. He currently acts as the research director for the school of healthcare and as the deputy head of school. His research spans sporting populations and NHS groups and predominately focuses on tendon disease - tendinopathy or ruptures. He has completed a PhD on achilles tendinopathy. Seth is currently researching tendon structure and changes that occur during health and disease along with biopsychosocial interventions for tendinopathy and back pain and developing an international database of calf injuries.

Dr Ebonie Rio is a Sports Physiotherapist at the Victorian Institute of Sport, The Australian Ballet, and she consults to multiple AFL, Rugby, elite Soccer and Basketball clubs. She is the Principle Research Fellow at The Australian Ballet, a joint position with La Trobe Sport and Exercise Medicine Research Centre. Ebonie co-leads activities in the High Performance 2032+ Strategy in Research and Innovation. She is the Deputy Manager of the Physiotherapy Department at VIS and co-chairs the research council. 

Do you want to learn more about tendons? Ebonie recently did a practical with Physio Network on this topic. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Ebonie's Practical here with our 7-day free trial: https://physio.network/practicals-rio2

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio from Physio Network

SPEAKER_02:

Welcome to Physio Discuss, the podcast where we dive deep into the world of physiotherapy with leading experts in the field. And today we have two incredible guests to talk through lower limb tendinopathy. They are none other than Dr. Seth O'Neill and Dr. Ebony Rio. Dr. Seth O'Neill, the Director of Research, Deputy Head of School and Associate Professor at the University of Leicester, holds a PhD on Achilles tendinopathy and is one of the world's foremost tendon specialists. His passion for advancing Thank you very much. In today's episode, we will be covering lots, including the current evidence for managing lower limb tendinopathy, how to differentiate between various lower limb tendon issues, some of the common rehab exercises used for tendinopathy, the role of inflammation, and we'll look at the future, what is in stake for tendinopathy management, and are there any exciting developments on the horizon. Stick around because by the end of this episode, you'll have a clearer understanding of the latest approaches to managing these challenging injuries and will reveal some surprising insights that could change the way you approach tendon care. I'm James Armstrong and this is Physio Discussed. Ebony, Seth, thank you so much for coming on to Physio Discussed today. I've been super excited about this as we chatted off air. You're going to have loads of questions for me just as an interested listener apart from the host today. So thank you for joining us.

SPEAKER_01:

Pleasure. Thanks for having me. And I'm sure everyone needs to say the same.

SPEAKER_00:

Yeah, thank you. It's going to be fun.

SPEAKER_02:

I'm sure the listeners will be very aware of your roles in this lower limb tendinopathy, which is what we're going to be talking about today. Both of you are big names in this field. So I think the listeners are going to be really excited about listening to what you've got to say and some of the points that will probably come up from today's episode. So I thought we'll dive straight in. I kind of wanted to pick your brains around where we are currently with the evidence around management of lower limb tendinopathy. It's a broad subject, but I thought we can pinpoint kind of the current state of play in that. Seth, do you want to kick us off with that?

SPEAKER_01:

That's a hard question to start with as well. I guess in overall summary, the evidence is really a lot of the adjuncts don't seem to offer a huge benefit. And then progressive loading particularly seems to be the mainstay from a physiotherapeutic perspective, at least, maybe some difference of opinion in sports and exercise medicine fields. But I think that's really where we're at in the nutshell of it. And it doesn't really matter. We will look at the higher tendons as we just discussed, so that the proximal ones around the hip or our sort of air Yeah, I

SPEAKER_00:

agree. I think that's a really nice summary. And I think one of the biggest challenges with bringing together the research is you can't read like one paper. You know, we can't do, you know, one of the other questions that you have for us around, you know, is there the right exercise? No, there isn't. There's not one exercise. And so we need to stop going, is this better than this? That's so short-sighted. If you've got someone in front of you that wants to run a marathon or play with their kids, you know, their start point and their goals are completely different. So we need to be informed by the evidence, but we can't just pick up a recipe. And probably a really good clinical example of that is the heavy slow resistance programs are fantastic. You know, they really give us an insight into that early loading, but they're both the Bayer and the Kongsgaard programs are both double leg. And we know that people are asymmetrical and need to load on each leg to change that asymmetry. And secondly, as sets fit, they don't have that progressive energy storage in stage. So when we're reading research and trying to get across the current state of play, we have to understand that what we're reading is the researcher has asked a really specific question. You know, how does this compare to this? Or how does something change over a finite period of time? But the person in front of us is goal-based, not time-based. They will come and see you until you sort of help them back to where they want to be. It's the nuance of being informed by the evidence, But trying to put it all together is the challenge.

SPEAKER_01:

And I think part of what we discussed at the last training conference as well of the groups that are in the research don't necessarily sort of meet our typical patients that we see, depending on our niche areas that we all work in. So whether this is typical national health service provision in the UK, whether it's comparing with elite sports and then what elite sports groups we're talking about in terms of jumping athletes field-based sports and comparing football by that i mean soccer with sort of any other footy that exists in the world so aussie or american or rugby and the various codes the athletes are very different and even within something like rugby a prop versus one of the backs that they're grossly different athletes just physically in terms of size the demands of the game there's some debate about whether actually there is that a bigger difference there but That's part of the nuance of the patients we've got to manage. It needs to be individualized care. And that's probably the big gap in the literature again at the moment of it's a case of his program. Everyone gets the same thing, but actually the nuance of how and where that may best be applied might be very different. And we all want to do an RCT, but let's face it, RCTs aren't really what help us manage a patient on a Monday in the clinic. So that's the bit, again, we just need to think about as well.

SPEAKER_02:

It's both saying there's a limitation to all research in this field, isn't there, in the sense that it can only tell us so much. And in my eyes, we're talking about there's no right exercise, but quite often in the research, we're looking at a certain stage of that rehab. And as we know with tendons and a lot of the athletes who might be thinking, there's a long program here and we need to get them to an end goal, don't we? And that's very hard to carry out in one RCT.

SPEAKER_01:

And a lot of the... interventions are quite unidimensional because of the nature of research that they're not eclectic like our hopefully anyway like our normal clinical interventions are so they'll focus on the muscle or the tendon they won't actually often look holistically at the person and how to manage the person and that creates a big sort of mismatch then in the research it's relatively biomedically focused instead of being biopsychosocially focused and That's the problem we've got. Again, it's not how we should manage individuals. It's not how most of hopefully do manage them, but it's the research doesn't tell us how best to manage those individuals that might have a much more psychological domain as has certainly come out in the Achilles literature from Karen Silbernagel's group and stuff with these subgroups that seem to exist. So yeah, a lot of questions need to be asked around that. And that's maybe a start of individualization.

SPEAKER_00:

I agree, but what we're both not saying is that people should just be like gurus and just do whatever they think. You can still be informed by the evidence and understand rate of loading as it helps you for diagnosis, understand rate of loading as it helps you for exercise progression. So that's really feeding back to the point around being evidence informed, but not recipe based. And one more thing that I like, Seth was talking about the different sports, even for people that don't work in elite sport, you need to really think about about the context of how you're applying that intervention as well so let's say exercise so you need to think about is this person in season now that could be occupationally in season they're currently at work they're a nurse they're on their feet 12 hours a day applying a eccentric only program to an in-season athlete that is an in-season athlete we know they do poorly so what we need to do is always think about the context of the exercise you know am I rehabilitating someone do I had the ability to manipulate their sporting loads, their loads in life, or am I just managing them at the moment because that's where they're at? So even with some of the great research that has been done, we can't apply that blanketly to all of the contexts, let alone, as Seth said, the individuals and their own kind of nuances and other health challenges and all of that stuff. That's a very long-winded answer to your very first question.

SPEAKER_02:

I think we've covered it really well. The takeaway there is there's shortfalls in the research, but that doesn't mean the research can't influence what we do and support what we do with our patients with a patient-centered care approach, essentially.

SPEAKER_01:

And learn from other areas where the research is totally applicable to tendon patients, like back pain research on biopsychosocial management, for example, or lifestyle interventions that we might utilize for patients. And we can pull from some of the osteoarthritis research then and apply the same approach to tendons even if the exact disease pathology may differ slightly it's got huge huge amount of similarities and actually changes some of those metabolic components probably absolutely crucial but we lack a bit of detail around the research there

SPEAKER_02:

there's a human at the end of of every tendon

SPEAKER_01:

that's where you need to look up above them so remember that

SPEAKER_02:

absolutely absolutely i want to go on to the next point here actually and ebony some of your master classes for the the physio network have highlighted this one as something that I've really taken away and changed my practice. And that's differential diagnosis. When we're looking at tendons, I've certainly looked back at my practice and thought, my word, I have treated so many patients as a tendinopathy and they may not well have been a tendinopathy.

SPEAKER_00:

Oh, me too.

SPEAKER_02:

And it really was an eye-opener. So let's talk a bit more about the, I suppose, the importance of differential diagnosis. Ebony, let's start with you. Is it important? I think we're going to guess it is. Talk to us a bit more about that.

SPEAKER_00:

Yeah. So if we take the Achilles, there is a lot going on back there and the devil's in the details. So if we just think of the tendon and the peritendin, if we just ignore the joint for a minute and we ignore the superficial bursa, we ignore the sural nerve. If we just think of tendon and peritendin, we've already got two conditions that respond completely differently, the loading and present completely differently and need clearly different paths. And I'm going to explain why. If you have someone with tendon they're aggravated by higher rate of loading. So the faster activities are more provocative, but we know that characteristically they warm up only to be worse the next day, but they had this warmup phenomenon and they have quite focal pain. When you have someone who's irritated the outside sonobulae, the peritendin layers, they get worse the longer you go. So it's a sliding, gliding, it's a sheer force. It might be that they swim, they row, they cycle. Or it might be your runner that doesn't warm up. They get worse the longer they go. And that's because they start running. Their calf isn't too bad. As they fatigue, they overload the peritendin layers. What they have is this diffuse pain. But critically, they actually have a very, very different pathology. So the pathology is different. The nociceptive driver is different. But forget all that. The rehab's different. For someone with mid-portion Achilles, I hope they leave everyone's clinical practice with some sort of calf loading program in some way. I almost don't even care how it looks, but I want them to have had some sort of calf exercise intervention. That's best practice. But if you have someone with a hairy tendonitis, and even though it's not inflammatory, I'm purposefully using that word because I want everyone to differentiate it from tendinopathy. If you have someone with an Achilles, hairy tendonitis, or carotene on issue, they're interchangeable terms. If you give them calf raises, that is their provocative load. Movement is their provocative load. So they'll get worse. So the person in your clinical practice who isn't doing well with an Achilles program, you have to really consider that it might be the differential diagnosis. So I think it's critical because it's the education we give people when to listen, how to progress. It determines the exercises we might start someone on. But every time someone thinks they've got a tricky tendon, it's very likely that would be something in, you know, some of these conditions coexist. You can have a peritendinitis with an underlying tendinopathy, but you have to know you've got that so that you can appropriately manage them. And they don't do well with the general exercise is good for you, you know, do great at exercise program. It needs to be very specific. And that's where the bio in the biopsychosocial really highlights how important it is.

SPEAKER_02:

Seth, do you want to add anything more to that?

SPEAKER_01:

Yeah, no, I think differential diagnosis is a massive component of these. As Ebony was just talking about with the peritoneum disorder, they're often triggered by excessive external compression. So boots or footwear that's high with a stiff heel counter or even actually strapping that we've applied to our athletes during football and rugby games, trying to stabilize the ankle. So there's often that element and actually part of what we need to do is remove the compressive components and the positions that are maybe causing that around the external compression of the sheath on the tendon. So you reduce the friction. So yeah, really critical. I can't stress that enough with it. And then again, just sticking within the tendon, there's so many different categories of disorder within the tendon that is evidence that the zone of tendinopathy being like the ventral or dorsal surface might have some different pain presentations in terms of the impacts on their functional capabilities and the severity of the pain. There's not a huge amount of evidence about that, but where it's been looked at, there seems to be some evidence around that. And then within the tendon, we might have a plantaris induced Achilles problem. People promote removing them. Again, we've always had the plantaris in that position. We don't necessarily need to run to removal, but it might be these don't respond in the same way. So it's a consideration there. And then a whole variety of splits and tears that can occur in the tendon. And again, in my hands, I make a lot of worse if we load them particularly if we load them early in quite aggressively so they need i think a very different nuanced intervention and unfortunately in the literature they all just get chucked together it's the case you've got a sore tendon we've got an insertional and mid portion as well as the paratina and chucked in as well and they all get thrown together and then the insertional groups you can split into okay is it bursa predominantly is it bone predominantly the Haglund deformity or actually bony edema, or is it the tendon? Or actually, normally, obviously, it's a combination of all of them. It's all internal compressive loads on that region. And the management just doesn't get considered or split out. They all get amalgamated together under the umbrella term. And it's often the important bit is the nuance. And as Ebony was saying, some of these people have been Managed for ages using regimes that are often not always appropriate. And we've all done it in the past as we've been learning. And hopefully then you get past it, but you still have mess up where something gets missed. And a bit later on you go, damn, yeah, if I'd spotted that early on, I would have done something different. And actually you tried the different thing. And lo and behold, they actually get better in a reasonable timeframe. So it happens.

SPEAKER_02:

We haven't got time to go down this route now, but surely as well, the attention is in the details and the attention of your assessment as well, because there's some key things that are going to tell you what's going on in your assessment if you're looking for it in terms of a tendon, in terms of its high load, what is a high load and that sort of stuff. And again, I've got a lot of this from Ebony's masterclass, and I think that's really worth checking out because it goes into a lot more detail around that. And obviously a lot of the work, Seth, you've done in terms of that loading of what a tendon actually responds to and how you might see that. And you mentioned insertional and mid-portion. Seth, do you want to just briefly, for those listeners who have come across those terms, just sort of highlight the differences and what we might see between those two?

SPEAKER_01:

Yeah, I guess the insertional bit is not often considered the true attachment. So where you've got sharpies fibers and actually the insertion into the bone proper is where the tendon actually gets compressed over the superior sort of aspect of the calcaneum. during dorsiflexion, for example. Most insertional tendinopathies have a clear bony cam that compresses into tendons. And again, this is why we often see bony spurs forming or calcification within the tendon. It's the body's way of coping with high compressive loads. It lays down bone that the tenocytes morph into more of a chondral cell or actually an osteocyte starts to produce bone or carthage. So it's all part of that mechanism and gives us the evidence that compressive loads are part of it. And it's not just against the bone. There's an internal compressive element as well. When you pull on the tendon, so as the muscle contracts, you're going to get some internal squashing. Add in then a bony element, it seems to create a bigger response in the tendon. Now, equally, this is healthy and it's normal and the tendons are perfectly robust and able to cope. So that's always got to be a key message because what we see commonly now in patients is they're attending, having listened to podcasts and blogs, sometimes misinterpreted it, sometimes actually taking verbatim what was said. that these things are bad and we need to reduce it. And it's not the case. We may just limit it or try to reduce the amount of time in those positions in the early phases is often how it's turned. But really we're talking about a highly irritable tendon, not an early phase or a late phase thing. It's about irritability. So it's a good old fashioned sin factor is really part of this. And that's the bit often we forget. And again, sometimes it doesn't always get taught very well now on modern undergraduate courses as well. clinical reasoning and subjective skills as ebony and yourself just talked about absolutely crucial to all of our assessments and really is the biggest factor in any clinical consult we ever do

SPEAKER_02:

yeah definitely and as ebony just said a minute ago in terms of listening to sort of what does aggravate it what are the irritants is going to tell you an awful lot of information if you're prepared to open your ears and listen which is really important

SPEAKER_00:

So I can summarize that in a quote. So Sir William Osler said, I think he was like an 18th or 19th century physician, if you listen to a patient, they'll tell you what's wrong. If you really listen, they'll tell you how to get them better. And that is so true when it comes to tendons. They will tell you what is provoking them. If it's the superficial bursa and they're getting compressed or irritated by their shoes, they'll tell you. So we need to not be fixated on what we're calling it because often that takes us down a path of this is what we need to do. And as Seth said, sometimes we're not on the right track. If we go back to the person who is really provoked in dorsiflexion, then you think, okay, what do I need to do? Even if I have never heard of plantaris before, I need to limit their dorsiflexion in those irritable stages, as Seth said. So just really honing in on what someone's telling you is just so helpful.

SPEAKER_02:

Definitely. And I suppose that comes into nicely what we're going to talk about in a minute is exercise. And I suppose that prescription of exercise around ags and eases and what the patient's telling you, rather than a diagnosis, I've read a paper, it told me to do this, let's do this. You can actually tailor it to the individual that's in front of you. So rehab exercises, I think it's important we go through sort of this heavy, slow resistance, isometrics, eccentrics, concentrics, because haven't we been around the houses in terms of research of where we're going to go and what we should be doing? And it can be a bit of a minefield, especially probably to some of the students and more newly graduated physios out there. What are your takes on all of that? I know we've talked a little bit at the beginning about where we are, but specifically around rehab exercise.

SPEAKER_01:

The exercise does need to be tailored to what you're trying to actually return the person to, to some degree and where their deficits lie. And one of the biggest bits is around the lack of testing around the deficits that exist in neuromuscular function. or neuro tendon as well, I guess, with tricking with it. It's a book bear in mind. So we'll trick exercises at people, but we won't think what we're trying to do with the exercise. And it's the case of really, are we trying to adapt the tendon? Are we trying to adapt the muscle? So in terms of hypertrophy or tissue alteration and mechanics, are we trying to improve the neuromuscular performance? And then is that at high speed? Let's say high strain rates, is it actually just high force and actually load rates that we're after? Is it accumulative stress? Where is it that we're working towards? So I often just simplify it and target three things. You go for accumulative stress, peak load, and the rate of the load. And they're the three sort of key bits. And the biggest challenge for tendons, as everyone always says, it's the faster activities where you've got shorter contact times on the floor. So bigger tendon demands, they're what tend to provoke and irritate the most. So often that can be a tricky bit. And your exercises need to work around those. And whichever you're focusing on at that time point is the key aim. And Ebony's just said it, the patients tell you which one's the biggest factor for them. If we can make that particular movement or activity better, we've made the patient better, or I should say, help them make themselves better, because that's really all we're doing. And if we can empower them to get themselves better, and they can focus on the activities that are most problematic, it's a win-win.

SPEAKER_00:

I agree 100%. If we consider tendons about the faster, the rate of loading, then by definition, anything static or slow for a tendinopathy is really safe. And so, you know, do they have to start with isometrics? Of course they don't. What they need to do is address their deficits. But we need to go away from like this one exercise to rule them all, even if we're thinking of like a calf raise. A standing calf raise doesn't necessarily ensure, particularly if we're giving an endurance set, you know, we're not targeting strength. We're not targeting anything in a bent knee position, which athletes really need for that change of direction and that eccentric soleus. So even if we're thinking of the calf, they might get seated calf, standing calf, standing calf endurance. They might get seated calf endurance. They might get an isometric sled push. There's so many different things where we go, okay, how does that person need to or want to use their calf? How do they want to function? And it's likely to include all of those things. So it's about clinicians being really thoughtful, not giving 7,000 exercises, as Seth said, being really clear on what my focus is at this point. And your focus might change, but that's why you test and that's why you reassess. So someone early on, you know, you might, start with three different calf exercises, but they're really specific. One is for endurance, one is for strength, and one is for top height if they're a football player that needs to kick in full range, you know, plantar flexion. But it's thoughtful and it's really targeted. Just giving the one exercise, you kind of do nothing well if you try and just be so generic that you're trying to cover off all bases. You sort of cover off none of them.

SPEAKER_02:

So that scattergun approach it is, or just that thoughtlessness, I suppose, or just thinking we'll just give this because it's a diagnosis and this comes back to again listening to the patient their demands where they need to be where they are now and how are you going to take them on that journey with specifics of your your prescription i suppose

SPEAKER_01:

i was just gonna say james everybody wants a recipe for how to manage these folk and it doesn't exist there is no sort of approach that works there never will be there'll never be one best exercise one best intervention one best program it's nuanced and it's individualizing the approach for each person we've got and it really needs to be very thoughtful like well you gotta do with an elite athlete versus the dad that fits in the odd weekend run versus the person that sort of walks down to the bus 50 yards from their front door and then sits at office all day and doesn't do any exercise it's hugely different and to give them all the same type of exercise and the same dosage not great but equally we need to dose it appropriately as well and we get lots of folk who are totally underdosed and one of my Real bugbears is actually seated soleus work or seated sort of calf work because it's just often absolutely minuscule in comparison of what the person can lift. And often when I'm teaching, I'll say, okay, well, what weight am I going to lift on the machine in somebody with like 50, 60 kilos, that's high. And I'll say, well, come sit on my knee then and we'll sit sort of the bigger person in the room on my knee and you'll be able to lift them perfectly fine. And it's the equivalent there. And I know there's some elements of physics within the lever arm of the machine that you might use that amplify the stress a bit, but ultimately gets the message across. We can lift 100 plus kilos easily versus the 30 to 50 kilos that we were probably doing on that same machine. So let's be realistic with our dosage as well.

SPEAKER_02:

That's really interesting. Ebony, did you have something you wanted to add as well?

SPEAKER_00:

So when I've done podcasts, I'll often say at the start, you know, my least favorite question on a podcast is what's better, isometrics or eccentrics? Because it's the wrong question. We should be saying, what does that person need at what time? They need both. So much of what we do is quasi-isometric, but actually we need our muscle and our tendon to be exceptional eccentrically. Seth made a great point then around setting up objective markers for people. We often base things on pain and really what we should be doing is respecting symptoms absolutely. So, you know, people's stiffness and pain and teaching people about managing that because it's not all just getting rid of pain, it's actually managing it while we improve function. But setting up objective markers so we're setting people up for success. You know, if you want to be an elite athlete, we have some reasonable criteria ideas around the parameters of where you need to be and they're high but they should be because they're putting unbelievable loads through their body and we can titrate that down for the people in front of us for the mum or dad that does the weekend run so we can manipulate those up or down but I agree with Seth most of the people that I see that I'm asked to do second and third opinions are just not being loaded as much as they're capable of and what the needs demand for what they're trying to do and so they're constantly in this state of overload in terms of not having the capacity to tolerate the loads.

SPEAKER_01:

Overloaded, underloaded, or loaded in non-relevant positions. So the other sort of thing is we often call it the Purdom effect. So Craig Purdom, who Ebony obviously used to work with a lot, came up with a bit of a nuance around just putting them in positions that replicate on field demands and really it's one of the key bits you've got to think about with all your rehab is we love our gym based exercises but it has no bearing in what position that the tendon gets stressed on field so make sure our exercises work towards that and you pretty much guarantee with your patients that they'll have a position that hurts them they avoid it especially if they're a skilled mover they manage to work around that and never go into that position or not so often until they're in the competitive play conditions and that then keeps provoking it so you It's having that chat, finding these positions that hurt and working towards that to clear it in order to get them better. And as soon as you start doing that with your patients, it expedites the whole process. You're loading the tissue in the way that actually hits the lesion and that will start to then get some modifications that we want in and around that area. this is then the benefit that we're getting from a clinical perspective. But also it's showing them it's safe because you're provoking pain, showing them it's not going to flare up. That has a massive central sort of reduction in their pain experience as well and just de-threatens it massively. It's a win-win really.

SPEAKER_02:

Do you think sometimes as physiotherapists, we let our patients, these patient group go too early? As in we finish our treatment, is it like too early? We don't take them to the point where they actually need to be?

SPEAKER_01:

Totally. I mean, my PhD data, I looked at that and despite excellent clinical recovery, like a 30 point shift on a B's or A's score, we were still massively miles away from their normal neuromuscular function when we compare it to control groups. And obviously Karen Silbernagel has done work around that. I can't remember if there's any other real good quantified bits, whether you've done stuff on that, but basically that's where there is big deficits. We've still got And the other factor is often their healthy side's not actually great, depending on what measures you use. So in my stuff using isokinetics, the good leg is the same as the bad leg, statistically speaking. So it might be a few kilos better or a few newton meters better, but there's not often a huge difference unless you're the person's in quite profound pain, then you'll see a side-to-side unilateral deficit. And so this creates a problem of we always use the good leg as the target. The good leg is probably not where strength and endurance deficits, performance deficits that exist well after symptom resolution. And some of this is probably why we see relapses in these individuals. In my data set, the actual plantar flexor strength didn't exceed a known previously published risk factor level. So you just then start to go out hang on a minute, we rehabbed them, we hit 49 newton meters as the average, but below 50 has been identified as a risk factor in other studies. And it's like, well, that's probably why we have a relapse. It should be, we know, certainly for Achilles, much more likely to get problems on that good leg in the next year. So we've just got to be careful when we're using targets as well. And this is partly why we spend a lot of time looking at sort of normative data, trying to get a big data set on what a healthy person looks like, but it has to be linked to specific sports. because comparing everyone in my village, let's say, the demands they have is profoundly different and you can't really then come up with a meaningful target. And I totally appreciate norms aren't a great option always as well. Ebony, anything

SPEAKER_02:

to add to that talk?

SPEAKER_00:

I think your point's really valid around objective targets. Most people that you assess, when you assess each side, they're down because they've had this kind of period of unloading or dysfunction. So making sure that everyone sets clear markers that apply to each leg. We know that from a neuro perspective, you actually have bilateral changes to your motor control, even with a unilateral presentation. We've seen this in the ACL literature, the limb symmetry index improves because the control leg gets worse. So that's not a good outcome for either leg. So just having those objective markers, but to go back to your first point around, do we sort of follow people through? One of the ways I think we can work towards that both in research but also in clinical practice is Laura Mimosley's four questions of self-efficacy so people want to know what's wrong with me how long will it take what can I do about it what can you do about it And if people are really clear from the start on what their end goal is, then that helps. Because I think what happens in research and clinical practice is people actually change their end goal. So people have actually stopped doing some of their provocative activity because of pain, dysfunction, life gets in the way. So they've altered their ceiling. They've changed their endpoint. And sometimes you see it with gluteal tendinopathy. You know, I've had people that are profoundly dysfunctional and their goals are very conservative because they just can't see the light at the end of the tunnel. Angie Ferron's work shows that the average time to diagnosis for gluteal tendinopathies, 18 months, these women present to the ED department. They're in so much pain. That is a failure on us. Like that is unbelievable. How is this happening that people are turning up at emergency department because their pain is so bad? So allowing people to have those lofty goals and helping them get there and not overselling the adjuncts. Circling right back to what Seth said at the start, there is not great evidence for adjuncts. And so if people early on have spent a fortune on all the injections, all the shockwave, all the things, it can be even harder to engage them in the long-term kind of process to get back to where they want to be because they're financially and kind of emotionally a bit burnt.

SPEAKER_02:

Brilliant. Brilliant summary for both of you there. Really, You mentioned injections. We're not necessarily going to talk about adjuncts, but I did want to just touch on the issue around inflammation, its role in tendinopathy. And if we look back maybe several years, a lot of people may still hear it referred to as a tendinitis. Where is inflammation now and how are we seeing it in tendons and tendon injury?

SPEAKER_01:

Yeah, I think it's still a contentious issue in many respects. So there is still a difference of opinions that exist out there in the literature. But I used to sit on the camp that it was purely degenerative. And part of that is because it's not prostaglandin-driven inflammation like we learn about at an undergraduate study like you with a knee sprain, ankle sprain. But the more you get into it, the more you realize that there's a huge amount of interleukins involved, which are these cytokines. So these are inflammatory mediators. It's got differences to typical big scale inflammation that we think about with knee sprains and similar elements. But these interleukins are a huge part of what stimulates the cell and creates the negative effect. And work from people like Neil Miller, Steph Dakin, they've published some fantastic sorts of papers showing how these chemicals are excreted by the cells. And this leads to the breakdown in the tendon structure. and everything that goes with it. So whether that's cell numbers, some low-grade inflammatory cells that come in as a consequence, and then the near vessels that all occur as a consequence. So the evidence around that, I think, is pretty robust there. But it triggers a degenerative cascade. It's just actively mediated. And I think this is where we all get pet up about it. But it just depends on your view of what we define, I think, as inflammation. And if you're looking at it from a three eyes perspective. So this is about the university group that specialise in infection, immunology and inflammation. It's clearly inflammation. But if you look at it sometimes from a clinical physio hat, we sort of say no. And it's just nuance around that, I think, really.

SPEAKER_00:

I agree. I think it's really complicated or complex. And I think the cytokines have multiple roles. So I think it's kind of two parts to it. When we used to use anti-inflammatory for an early hamstring strain, brilliant, we're blocking inflammation. Some of those cytokines had really important roles in scar. And what happened was it was associated with an increased recurrence. So I think because it is so complex in terms of the pathology, it's unlikely that an interleukin that we block doesn't have other signaling roles. And so even if we find the pathology, it will be interesting to see what we do with it and whether or not that's clinically helpful. And I think I agree, the work they've done is outstanding and I think it's really working towards a better understanding of what we can do with it. But for me, where we're at at the moment, what we've got to avoid is the public perception of that this is inflammatory. And that's why I rally against the term tendonitis, because if people think it's inflamed, their disconnect, their underlying understanding of what they need to do is rest ice anti-inflammatories, probably an injection, maybe a boot. And so that is so far away from what we're trying to encourage people as best practice. And there's a great systematic review by Nickel in 2017, which manipulated terminology. And if you tell people that they have a fracture, 56% of people think that they need a plaster cast. For the same injury, if you say cracking the bone, 13% of people think they need a plaster cast. So every time we're choosing a term or allowing people to say a term that we don't kind of go, oh, actually, this is a better term, they are updating their understanding of their condition and more importantly, what they need to do about it. So I think the debate around inflammation is fantastic. I think it's currently one for the research and the academic world. I think from a very important language and implication point of view. We have to stay well away from it or there's a disconnect between what people think they need to do and what we're offering. Therein lies the nuance, I think.

SPEAKER_01:

I think you're right. But then equally, you have to be careful about the generative terminology as well, because that triggers exactly

SPEAKER_00:

the same stuff. I agree. I hate that term. It's so bad.

SPEAKER_01:

This is again where they'll read a whole variety around. So one of my opening questions is with the patient is, okay, so you said you think you've got an Achilles tendinopathy, let's say, or if they've used tendinitis or tendinosis, they don't normally, they don't normally use tendinopathy. So what do you understand that is? And what does that mean to you? Because that's the key bit of unpicking our yellow flags really in working out the impact of their belief on their sort of self-management, self-efficacy, and what's then going to be acceptable from our management perspective. And if we don't unpick it, we can't actually break through. And these are the biggest barriers to then doing something that is really a behavior change intervention. We're trying to get them involved to what they do to actually improve their behavior. Yeah, capacity to get better. And exercise, we know from our own experiences, I'm sure, is quite hard to adhere to. And that's the challenge. So we've got to be careful about the wording we use, absolutely.

SPEAKER_00:

Oh, for sure. And just to your point around their understanding of the condition. So we did a study, so Rick Clementi and I, a few years ago, says... 440 odd Achilles included, self-reported. And we asked people if they could do three calf raises and people that had higher kinesiophobia chose not to do three calf raises. So think about that in your clinical practice, not just that you might actually be prescribing that as an exercise without even thinking, you probably asked them to do it as your assessment and people are thinking, are you sure that's safe? And so the language we use and how we frame the intervention is so important. And to circle back to your point around inflammation. I'm with Seth. The term degenerative is as awful for me. I never use it. And I spend some time like Seth on not just their understanding of their condition, but if they've brought an imaging report, don't say to them, don't worry about your imaging. That's so dismissive. Take the time to actually talk them through it and try and help them understand it so that they feel empowered. But if you say, oh, don't worry about the imaging, they'll worry about the imaging and they'll Google it.

SPEAKER_01:

Yeah. I mean, I literally just, I was teaching last week that last two days, last week abroad. And it was one of the things that we came up with was imaging and the importance around it because of what it triggers. And therapists or clinicians need to see the imaging. It's not acceptable really to just accept the report you get given because the report hasn't always got a clinical slant on it. There's some fantastic radiologists out there who will do a clinical assessment and give you a then clinical meaning for this and represent how that sits with the patient's age, let's say for RA or something. But what happens is you get reported, identify a whole load of factors, but it's the context of the patient, their presentation. And actually, does it actually show a significant problem or are we actually really talking about a very mild, typical sort of presentation? And that suddenly threatens it. And yeah, we all use case studies to sort of identify how that has a massive impact on these individuals and the fear it can induce. You get told you've got an arthritic complaint that your back's crumbling or whatever. It's terrible. It's exactly the same for tendons. And we hear the same terminology. You've got the tendon of an 80-year-old. or it's going to snap if we don't do this procedure and these are some of the sort of things that we hear that patients get told regularly and that's what we've got to unpick because it is just yeah fear of movement it triggers this belief that they're fragile they're going to suddenly snap doing something and snapping or rupturing the tendons that most of the people's biggest concerns and as ebony was talking about how patients modify their long-term aspiration ruptures is where we see that the most people actually say they've had a great recovery and score well on some of the outcome measures when they're actually terrible but it's just they've modified what they're accepting as norm so originally they're doing sports they're then not doing anything at all and look if they're walking sorts of decent distances on hills and they're accepting that and scoring those really good recoveries so there's a lot to work around that

SPEAKER_00:

We've got a systematic review at the moment that show that most people with either current or past tendinopathy don't even meet the minimum requirements for physical activity, like less so than the general population, which is expected. But just on Seth's point around the imaging, you know, one of the things that I often say to people is this radiologist has done a fantastic job because it's their job to see every little thing and it's our job to explain to you which bits are relevant. So I think that can be a really nice way of people framing it to say, don't worry, you've got three-page report. That is a very detail-oriented, exceptional report and well done and thank you to the person that now allows us to interpret it because they haven't missed anything. But I agree with Seth, you've got to look at the pictures.

SPEAKER_02:

I love that idea actually. Yeah, when you get a big report with lots of findings, is actually put the positive on it from the patients and reassure them that actually they've done a really good job here, but let's unpick this together at what's meaningful to you. That's fantastic. Yeah, really like that. What's the future of Like for lower limb tendinopathy, where are we going and where would you like to see us go?

SPEAKER_01:

So I think we need to, for us in the UK, we need to research patients that actually replicate the patients that we see regularly from an NHS perspective, which is most people's clinical practice, because it does not match that. And the interventions that we then develop need to be co-designed with the patients. They need to encompass behavior change techniques that are evidence-based and not just sort of the whims of ourselves. And we need to look a bit broader than just the tandem. We need to look at general lifestyle interventions and really unpick the influence of multiple morbidity, which is really what we've identified in the work we've done over the last five years or so in the UK. And that's the biggest bit for us, is making sure the research is fit for purpose with the people that most of the clinicians in the UK see regulate, alongside then some of the sports stuff that we do that is a bit more niche.

SPEAKER_02:

Brilliant, sir. Thank you. Ebony, where are we going?

SPEAKER_00:

Ideally, where we're going is that tendon research is... really well funded it's really hard to get funding and we we know that as seth said people end up often with consequences of their tendinopathy that then impact their general health, which then has a downward spiral. So, you know, a really common presentation is an older person with Achilles pain or, you know, glute med pain. They put on extra weight. They become pre-diabetic. They just get into this cycle. And we know from the diabetes research that their bills increase for the eight years before diagnosis. And one of the earliest presentations is musculoskeletal. So we are seeing people that have tendinopathy that then has this consequence, but we can't make an argument for that the way the joint folk do, because that has a... surgical outcome and so that's where funding bodies see being able to save money is delaying or preventing surgery but because these people bounce around they cost a lot of money and they have a lot of impact on their life but it's really difficult to get funding to research this. My future is that we somehow manage to be relevant on a world stage the way osteoarthritis is. It is as debilitating as osteoarthritis but for my mind it's because there's no surgical consequence and rupture is relatively uncommon compared to joint replacement and stuff and even now with the conservative option for post-rupture it's really difficult to be relevant on a world stage and by think we've got some ways we can work together and do that. I think we need to better define what tendinopathy is. It's not even on like the who classification. We sort of don't appear anywhere. So I think as a kind of disease or injury, we need to work together. I didn't answer your question, but that's my little rant around funding.

SPEAKER_01:

I think, I mean, the Dutch studies have identified that lower limb tendinopathy is more prevalent and has a higher incidence rate than lower limb osteoarthritis. That's not taught at universities. And the consequence of something like gluteal tendinopathy is actually in a progression to osteoarthritis with Vanjie's work. But it's maybe not. We need some bigger data sets to really hammer that point home. And this is, I think, where... Research needs to go. It needs to be international. We need to do, this is what other areas do where I work. They'll do cohort in Australia, cohorts in Europe, cohort in sort of America. So you get these multiple cohorts all pointing in the same direction. You certainly got a much bigger numbers case and that really helps. And health economics need to be part of this as I've been able to talk about the cost of this downstream on the individual, their quality of life and the economy in the area. It is huge. And that's the big gap. And that's where we've all done our own little side work and need to actually come together on something like an EU horizon project. that actually brings in a multinational group of us to do something. And I think that is happening in the tendon world. It's the ISTS group. It's now the core outcome set out there to go, hey, this is what tendon research should include and discuss when you do an RCT or whatever trial you do, but the key things to report. So we're starting to get some cohesion, I think, and that will really help as well.

SPEAKER_02:

Brilliant.

SPEAKER_01:

And then we've got to prevent it. That's the last thing. We must prevent adenopathy. That's it, done, sorry.

SPEAKER_02:

Brilliant. I think it's a really, really good point to finish on because it just highlights how vital our role is in correctly and assessing these patients, treating them as best we possibly can with the most up-to-date kind of knowledge and evidence. People listening to this, I'm sure, will go away straight away with a much better understanding of how they can manage their patients and an understanding of how important it is, as you said in the latter stages of this, of the repercussions of these patients going round and round and round. It's not just a tendon at the end, is it? It actually can end up being something far more life-changing for a patient. So I think that's quite a profound place to stop today. Thank you both so much for your time. Seth, go and get some sleep. Ebony, have a good working day. Thank you so much for both of you joining me on the physio disgust podcast our listeners are really i'm sure gonna be very grateful of your time as am i

SPEAKER_00:

thank you

SPEAKER_01:

thank you very much for having us