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The first thing for me is recognising and removing our provocative load.
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Now for the peritendon, that's movement.
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And the reason why it's an important one to differentiate is I can't give these people calf raises because it's movement.
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But someone with a mid-portion or an insertional Achilles, calf raises is a fantastic start point.
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Tendinopathy, it's super common.
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We all see a lot of it clinically and the research is very fluid.
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It's moving.
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We've seen things about isometrics, eccentrics, heavy, slow resistance.
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So how do we know where to start?
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Well, today we've brought you Dr.
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Ebony Rio.
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Now, Ebony is so well researched in this area.
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She's a researcher at La Trobe University and she's currently working at the Victorian Institute of Sport.
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She is absolutely wonderful in this area.
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She's got clinical experience.
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working with the AIS in the Winter Olympics as well as the Australian Ballet.
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I can't think of anyone better to talk to about this topic.
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I hope you enjoy this episode as much as I did.
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I'm Michael Risk and this is Physio Explained.
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Hello Ebony, thank you for joining us to talk about tendons.
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Thanks so much for the invitation.
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No
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problem at all, we're going to get straight into it.
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My first question was, with all this knowledge you've accumulated, is Where do we start with tendons now and how do we start?
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Because I was mentioning to you off-air, I got a little confused wanting to start with isometrics.
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It used to be heavy eccentrics and it's always patient-centered and individualized.
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But what tips would you have about that?
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Yeah, that is an excellent place to start.
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So I think where we need to start with tendons is to always understand that it is patient-centered.
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And the critical component of that is to listen to your patient.
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And that actually really helps us with our differential diagnosis.
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That's the first thing.
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So in terms of where we start with tendons, we want to make sure that we are giving appropriate advice and that we think we have someone with tendinopathy.
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So the key diagnostic criteria that they have really localized pain that's related to high tendon load.
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So this is not pain with palpation.
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This is not pain with low tendon load.
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And just to give you an example, in the patella tendon, it can be incredibly sensitive even in people with knee osteoarthritis.
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But I wouldn't imagine that clinically you're going to give the same program to someone that has knee OA and tendinopathy.
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So differential diagnosis matters when you create different advice and different treatment plans.
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So to understand tendon load, you need to know that in our lower limb, most of them act like a spring.
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And anything that's fast is what's high tendon load.
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So it's got to be fast for it to be high tendon load.
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So, you know, then Michael for the Achilles, that's things like, you know, running and hopping.
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But actually we use our Achilles tendon like a spring throughout the lifespan, which is why clinically we can see a really heterogeneous group of people from, you know, young athletic people to our older, more sedentary.
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But the patella tendon is quite different.
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We pretty much only use the patella tendon like a spring with, you know, really explosive jumping.
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So that gives you an idea then of who you see clinically, you know, young elite jumping men and almost no one else.
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You want to be able to recognise compression in tendons because clinically it's a really nice one to remove.
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It really helps us a lot with pain and knowing that that energy storage combined with compression is our most provocative load, but also what tendons are designed to do.
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So we shouldn't be scared about getting people back to it.
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The final load to really understand is that friction load.
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And that's what I was talking about in terms of differential, because if you give someone with a peritendin issue, a Vichyli's, um, or heavy eccentrics or any of those things, they're going to do badly.
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So we can reverse engineer that actually and say that someone with tendinopathy is someone that responds well to things that are static or slow because by definition, they're really safe for the tendon.
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Does that make sense?
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Yeah, yeah.
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I love that.
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I've got so many questions already.
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Great.
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When you said local tenderness, for clarity, would you be saying that this is probably not a tendinopathy if it's a more vague and along the whole Achilles?
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You're looking for like pinpoint tenderness to diagnose it?
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Is that what you mean?
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Yeah, great pickup.
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And thank you for clarifying because it is such an important point.
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When we're talking about the insertion, people can localize with one finger.
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When we're talking about the mid portion, they tend to pinch, but they don't move up and down their tendon.
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As soon as someone is moving up and down their tendon, I do want you to really be aware of that peritendin.
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They're actually trying to show you the peritendin.
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And so what that person will do is they'll describe different provocative loads.
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They'll describe non tendon load or low tendon load like cycling, because that's a lot of repetition where you're gliding the peritendin over the Achilles.
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So this will be someone that might've got a new bike or might've done a big ride.
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So that's your first key point in this objective.
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The second key point is around tendon pain behavior.
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So we talk about pain that remains localized, but also knowing that there's a bit more to it.
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Tendon pain warms up.
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So if you have someone with tendinopathy that can feel a little bit stiff and grumbly at the start, then they get better.
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But something like a peritendin gets worse the longer they go.
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So even in a run-up Michael, if you have someone who says, actually, I don't feel it till I'm, you know, at least five kilometres in, again, be aware that that could be the peritendin.
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even though running is heighten and load, if their calf capacity isn't good enough and they foot strike, if their calves have worn out, they'll start to go through big ranges of motion.
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They'll start to, you know, excurs, is that a word?
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They'll start to move the peritendin over the tendon repeatedly and that's why they get worse the longer they go.
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So we want to put all of their story together, which is why listening and really paying attention to the detail and the subjective is so important.
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So yes, it's Very local.
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Our lovely exception would be our glute med.
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Our older women with gluteal tendinopathy or gluteal bursitis, that compressive issue, because of all the bursa, they get referral down the leg.
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That's very common, but usually not past the knee.
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That's...
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We're going to go deeper into tendinopathy, but just quickly, I want to know what do you do differently for the peritendin versus the tendinopathy which we're about to get into?
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Yep.
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So if we're thinking of a peritendin, actually, if we're thinking of any condition associated, the first thing for me is recognizing and removing our provocative load.
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Now for the peritendin, that's movement.
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And the reason why it's an important one to differentiate is I can't give these people calf raises because it's movement, but someone with a mid portion or an insertional Achilles, calf raises is a fantastic start point and it's critical.
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So what I do differently for the peritendin is we have some strategies for reducing the irritation of that peritendin, but they have to go hand in hand with reducing the movement.
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So if that person is cycling, they need to stop cycling.
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If they're just walking around, you might consider getting them in a shoe with a higher heel so they don't go through as much range of motion while they're walking.
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So it these different strategies.
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And a few years ago, I would have said that you could try isometrics to try and keep them going.
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They hate it.
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It bunches up the peritendin.
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They hate you.
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Don't do it.
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Good info.
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That was a selfish question.
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I'm going to get into the tendinopathy.
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So what's the research currently telling us about isometrics, eccentrics, and HSR, heavy slow resistance.
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Where are you leaning to?
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Yeah, what I'd like everyone to really take away is that I want everyone to be evidence-based, but not recipe-driven.
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You will never be able to go to the research and take the protocol for every patient.
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So do all of those things have a role?
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Of course they do.
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And clinically, you work out what combination you might use, but you could never Never just give someone an isometric exercise and expect that you've restored their strength and their strength endurance and their capacity and their energy storage and made them tolerant to compression and that whole continuum.
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And same with eccentrics, same with heavy, slow resistance.
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If we're thinking about tendons of being a spring, we need the base.
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We need excellent tendons.
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strength and capacity in our muscles so that we have a really strong scaffold for our tendon to work off.
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But then we actually need to sort of sneak up on the tendon.
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Tendons hate change.
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So it would need to be very progressive.
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So to answer your question, it will never be one or the other.
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What I'd like everyone to do is work out how each bit of research can be integrated to build on their toolkit.
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Because those things are part of our toolkit.
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And as physios, it's our clinical reasoning to work out when to use them.
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So to give you an example, I love heavy, slow resistance.
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I use it, but I don't use the protocol that was published.
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And I'll tell you why.
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It was double leg.
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And we know from previous research that people with unilateral tendinopathy have asymmetries.
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So if I'm giving a double leg protocol, I'm actually not addressing those asymmetries.
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So what I want to do is take the previous research about differences in symptomatic and asymptomatic sides, layer in, you know, heavy slow resistance, but actually combine them rather than throwing out everything that's been done before.
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And it's the same with isometrics.
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I would not say that that replaces everything any of your rehabilitation, it's a tool that you might use as a way in, particularly for people if they're a bit fearful about doing something.
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It's a really safe load to start with.
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So it can be really good for their confidence and their self-efficacy.
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But is that all you should do?
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Oh my gosh, no.
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I love that.
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I'm an average physio with a bias towards strengthening.
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So I want you to tell me if I'm oversimplifying this because I think you'll have some pearls.
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I used to base it on irritability or aggravating the patient.
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So if someone was highly irritable, I would start with isometrics.
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If someone wasn't that irritable and I was confident it was tendinopathy, I would bias to go to eccentrics or HSR.
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Can you tell me what's wrong with that thought pattern or is there anything right with it?
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Hit me with that.
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Yeah, I think it's really good that you're being thoughtful about the person in front of you and how you'll sort of shape those decisions.
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So the key thing for me is we need to work out what the deficits are for the person and what their goals are.
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And Jill Cook and Sean Docking did this beautifully a few years ago in editorial, which talked about current capacity and goals.
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Because then what you can do is break down each of those steps.
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So the decision to start with isometrics or isotronics at the start, both of those are safe loads for tendons.
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If it's slow or it's static, then by definition, if it's a tendinopathy, you're laughing.
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Again, contrast that with something like the patellofemoral joint where a heavy isometric leg extension actually might provoke them.
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So again, it can actually help you with your differential and your clinical decision making.
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So in terms of where to start, it can be based on a lot of things.
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I had an ultra marathon runner who had seen a lot of a lot of physios and been given a lot of different advice, had a lot of interventions and he could do six calf raises.
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Now, he wants to run 160 kilometers.
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So, we didn't start with isometrics.
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We just got going.
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Actually, pain wasn't a big feature because he was so unloaded.
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He needed load.
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So, we started with strength endurance.
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We started with strength in the gym.
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So I think there's no right or wrong answer as long as people are thoughtful about what they start with and that they are addressing that person's individual deficits.
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Tell me I'm wrong, Ebony.
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It's okay.
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But it sounds like the better measure is like what their goal is and what their previous capacity was rather than what I was saying about irritability.
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Would that be about right?
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It can be, but irritability can definitely feed in, particularly if they are anxious.
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And a really irritable tendon or a person with a really irritable tendon will need a lot of education around if you have pain with exercise and I'm giving you an exercise, but I haven't dealt with the fact that these are safe loads and teaching people about what is the provocative load and what is the safe load, then people may not be adherent.
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So as David Butler would say, just meeting people at their story and really making sure they understand what what is safe to do.
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Yeah.
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But I'm less concerned with irritability, particularly early, because you're not giving high tendon load.
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You're removing that load, but just teaching people when to listen.
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So to listen 24 hours after the load.
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There's a study that's coming back to me talking about irritability.
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I believe it was on jumper's knee and it was volleyball players.
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So athletes that are experienced with loading, And I think they pushed into pain and did quite aggressive exercises and found they had a better outcome.
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Is that coming to mind for you?
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There's a couple of different studies that have looked at whether or not it's okay to push into pain.
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And in fact, the original eccentric work was almost based on progressing pain trying to get people to that level.
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So again, I think it's really individual.
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This is why I never like giving a number because for some people, five out of 10 pain, they always play with it.
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It's just not an issue.
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For some people, five out of 10 pain is completely unacceptable.
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So we talk about symptoms that are low and stable.
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So what I'm looking for is increasing our load while...
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people can maintain or reduce their 24-hour pain.
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So their symptoms are low and stable.
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So that doesn't need to be zero.
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And again, that's a really important education point for people.
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You're trying to aim for low and stable symptoms.
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Yeah, yeah, I like that.
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The question I was going to ask you, which I think you've answered, but I reckon you've got a bit more there.
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What's really changed for you in the last three to five years with what you've learned and what you've studied?
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How has that actually changed your clinical practice?
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Oh, I'm going to have to say the brain here.
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So, um, a much better understanding of pain, thanks to particularly Laura Mimosley and David Butler.
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So pain is produced by the brain 100% of the time.
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That doesn't matter if it's a paper cut, chronic low back pain or tendinopathy, your brain will produce pain to protect you.
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And in the case of tendons, that's quite useful because it tries to stop us overloading and doing really silly things.
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The other thing for me is the changes around the motor cortex and how we might need to in some of those principles into our rehabilitation to really improve our outcomes for people with tendinopathy, that it isn't just about tendon load and muscle load and kinetic chain.
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We actually need to appreciate the spinal cord and brain and just how complex it is.
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I
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love that.
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And that's, we're talking more chronic pain, persistent pain strategy, which we might use rather than just considering the tendon.
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Yep.
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And critical to that would be that we shouldn't reserve things like education only if we think we're dealing with chronic pain.
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Everyone deserves that respective language and that education.
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And a good example would be something like tendonitis.
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If people are using terms like tendonitis, their underlying...
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understanding of the condition is that it's inflammatory and you will probably not be able to convince them to do exercise because their understanding of what they need to do for that condition is likely based on rest, ice, anti-inflammatories.
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So just making sure our biopsychosocial-ness actually translates across every aspect of patient care.
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So the terminology we use, how we empower them so that it all marries up.
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If people are saying things like tendonitis and then we're giving exercise, we're probably doing them a disservice about really educating them about their body and their condition.
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Ebony, I think that would be a wonderful second chat with you about the central changes in tendonitis.
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But for now, I think...
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You did
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not say tendinitis.
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Tendinitis
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means it's inflamed.
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I can't believe I just said that after you just went on that rant.
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And so...
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I was even in this discussion about would it matter if therapists use that?
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But I love how you outlined that.
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If therapists are using it, patients are probably thinking it's inflammation.
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And then what do you reckon?
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They're
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Googling.
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Absolutely.
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And in fact, we're just starting a study on that.
00:18:36.442 --> 00:18:39.665
But the key thing, so there's actually a great paper by Nickel.
00:18:39.746 --> 00:18:40.946
It's a systematic review.
00:18:41.146 --> 00:18:47.451
And they looked at the impact of terminology on what people thought they needed to do about the condition.
00:18:47.491 --> 00:18:56.721
And these vast differences, even in terms of fracture, if you're saying crack in the bone versus broken bone as to whether or not people think they need a cast.
00:18:58.063 --> 00:18:59.904
Language is so important.
00:19:00.066 --> 00:19:01.686
I love that you've brought that up.
00:19:01.847 --> 00:19:02.769
Thank you so much.
00:19:04.250 --> 00:19:08.414
Well, I think that summary you just gave us is a great place to end it.
00:19:08.535 --> 00:19:10.136
So I'll leave it there.
00:19:10.196 --> 00:19:12.219
And thank you so much for your time today, Ebony.
00:19:12.799 --> 00:19:13.980
Oh, thanks so much for having me.
00:19:14.020 --> 00:19:14.942
Thank you.
00:00:00.066 --> 00:00:09.522
The first thing for me is recognising and removing our provocative load.
00:00:09.862 --> 00:00:11.945
Now for the peritendon, that's movement.
00:00:12.647 --> 00:00:18.378
And the reason why it's an important one to differentiate is I can't give these people calf raises because it's movement.
00:00:18.678 --> 00:00:25.109
But someone with a mid-portion or an insertional Achilles, calf raises is a fantastic start point.
00:00:26.786 --> 00:00:28.588
Tendinopathy, it's super common.
00:00:28.647 --> 00:00:32.151
We all see a lot of it clinically and the research is very fluid.
00:00:32.191 --> 00:00:32.890
It's moving.
00:00:33.292 --> 00:00:37.634
We've seen things about isometrics, eccentrics, heavy, slow resistance.
00:00:38.036 --> 00:00:40.237
So how do we know where to start?
00:00:40.338 --> 00:00:42.238
Well, today we've brought you Dr.
00:00:42.338 --> 00:00:43.039
Ebony Rio.
00:00:43.079 --> 00:00:46.143
Now, Ebony is so well researched in this area.
00:00:46.523 --> 00:00:52.588
She's a researcher at La Trobe University and she's currently working at the Victorian Institute of Sport.
00:00:52.969 --> 00:00:55.570
She is absolutely wonderful in this area.
00:00:55.591 --> 00:00:56.752
She's got clinical experience.
00:00:56.752 --> 00:01:01.438
working with the AIS in the Winter Olympics as well as the Australian Ballet.
00:01:01.939 --> 00:01:06.183
I can't think of anyone better to talk to about this topic.
00:01:06.644 --> 00:01:08.587
I hope you enjoy this episode as much as I did.
00:01:09.048 --> 00:01:11.230
I'm Michael Risk and this is Physio Explained.
00:01:13.013 --> 00:01:16.197
Hello Ebony, thank you for joining us to talk about tendons.
00:01:17.319 --> 00:01:18.560
Thanks so much for the invitation.
00:01:18.579 --> 00:01:18.620
No
00:01:19.320 --> 00:01:20.923
problem at all, we're going to get straight into it.
00:01:21.825 --> 00:01:29.816
My first question was, with all this knowledge you've accumulated, is Where do we start with tendons now and how do we start?
00:01:29.996 --> 00:01:35.251
Because I was mentioning to you off-air, I got a little confused wanting to start with isometrics.
00:01:35.331 --> 00:01:39.683
It used to be heavy eccentrics and it's always patient-centered and individualized.
00:01:39.784 --> 00:01:41.510
But what tips would you have about that?
00:01:42.049 --> 00:01:45.033
Yeah, that is an excellent place to start.
00:01:45.513 --> 00:01:52.099
So I think where we need to start with tendons is to always understand that it is patient-centered.
00:01:52.638 --> 00:01:55.762
And the critical component of that is to listen to your patient.
00:01:56.322 --> 00:02:00.305
And that actually really helps us with our differential diagnosis.
00:02:00.406 --> 00:02:01.527
That's the first thing.
00:02:02.268 --> 00:02:10.995
So in terms of where we start with tendons, we want to make sure that we are giving appropriate advice and that we think we have someone with tendinopathy.
00:02:11.034 --> 00:02:20.044
So the key diagnostic criteria that they have really localized pain that's related to high tendon load.
00:02:20.465 --> 00:02:22.266
So this is not pain with palpation.
00:02:22.287 --> 00:02:25.090
This is not pain with low tendon load.
00:02:25.150 --> 00:02:32.798
And just to give you an example, in the patella tendon, it can be incredibly sensitive even in people with knee osteoarthritis.
00:02:33.278 --> 00:02:38.944
But I wouldn't imagine that clinically you're going to give the same program to someone that has knee OA and tendinopathy.
00:02:38.965 --> 00:02:46.302
So differential diagnosis matters when you create different advice and different treatment plans.
00:02:47.066 --> 00:02:52.685
So to understand tendon load, you need to know that in our lower limb, most of them act like a spring.
00:02:53.153 --> 00:02:57.397
And anything that's fast is what's high tendon load.
00:02:57.437 --> 00:02:59.900
So it's got to be fast for it to be high tendon load.
00:02:59.939 --> 00:03:06.025
So, you know, then Michael for the Achilles, that's things like, you know, running and hopping.
00:03:06.705 --> 00:03:17.854
But actually we use our Achilles tendon like a spring throughout the lifespan, which is why clinically we can see a really heterogeneous group of people from, you know, young athletic people to our older, more sedentary.
00:03:18.536 --> 00:03:20.056
But the patella tendon is quite different.
00:03:20.397 --> 00:03:25.423
We pretty much only use the patella tendon like a spring with, you know, really explosive jumping.
00:03:26.304 --> 00:03:33.372
So that gives you an idea then of who you see clinically, you know, young elite jumping men and almost no one else.
00:03:34.493 --> 00:03:40.221
You want to be able to recognise compression in tendons because clinically it's a really nice one to remove.
00:03:40.401 --> 00:03:50.990
It really helps us a lot with pain and knowing that that energy storage combined with compression is our most provocative load, but also what tendons are designed to do.
00:03:51.070 --> 00:03:53.215
So we shouldn't be scared about getting people back to it.
00:03:53.254 --> 00:03:57.563
The final load to really understand is that friction load.
00:03:58.025 --> 00:04:11.002
And that's what I was talking about in terms of differential, because if you give someone with a peritendin issue, a Vichyli's, um, or heavy eccentrics or any of those things, they're going to do badly.
00:04:11.022 --> 00:04:28.422
So we can reverse engineer that actually and say that someone with tendinopathy is someone that responds well to things that are static or slow because by definition, they're really safe for the tendon.
00:04:28.502 --> 00:04:29.223
Does that make sense?
00:04:29.502 --> 00:04:31.504
Yeah, yeah.
00:04:31.524 --> 00:04:32.125
I love that.
00:04:32.290 --> 00:04:33.973
I've got so many questions already.
00:04:34.012 --> 00:04:35.194
Great.
00:04:35.815 --> 00:04:48.475
When you said local tenderness, for clarity, would you be saying that this is probably not a tendinopathy if it's a more vague and along the whole Achilles?
00:04:48.815 --> 00:04:51.620
You're looking for like pinpoint tenderness to diagnose it?
00:04:51.680 --> 00:04:52.262
Is that what you mean?
00:04:52.514 --> 00:04:53.774
Yeah, great pickup.
00:04:53.875 --> 00:04:57.317
And thank you for clarifying because it is such an important point.
00:04:57.759 --> 00:05:01.442
When we're talking about the insertion, people can localize with one finger.
00:05:01.982 --> 00:05:06.685
When we're talking about the mid portion, they tend to pinch, but they don't move up and down their tendon.
00:05:06.846 --> 00:05:13.331
As soon as someone is moving up and down their tendon, I do want you to really be aware of that peritendin.
00:05:13.351 --> 00:05:15.173
They're actually trying to show you the peritendin.
00:05:15.834 --> 00:05:20.598
And so what that person will do is they'll describe different provocative loads.
00:05:20.999 --> 00:05:30.235
They'll describe non tendon load or low tendon load like cycling, because that's a lot of repetition where you're gliding the peritendin over the Achilles.
00:05:31.041 --> 00:05:35.826
So this will be someone that might've got a new bike or might've done a big ride.
00:05:35.906 --> 00:05:38.649
So that's your first key point in this objective.
00:05:39.369 --> 00:05:42.711
The second key point is around tendon pain behavior.
00:05:42.752 --> 00:05:48.156
So we talk about pain that remains localized, but also knowing that there's a bit more to it.
00:05:48.377 --> 00:05:49.338
Tendon pain warms up.
00:05:50.038 --> 00:05:55.423
So if you have someone with tendinopathy that can feel a little bit stiff and grumbly at the start, then they get better.
00:05:55.463 --> 00:05:59.125
But something like a peritendin gets worse the longer they go.
00:05:59.146 --> 00:06:09.458
So even in a run-up Michael, if you have someone who says, actually, I don't feel it till I'm, you know, at least five kilometres in, again, be aware that that could be the peritendin.
00:06:09.697 --> 00:06:20.531
even though running is heighten and load, if their calf capacity isn't good enough and they foot strike, if their calves have worn out, they'll start to go through big ranges of motion.
00:06:20.572 --> 00:06:23.516
They'll start to, you know, excurs, is that a word?
00:06:23.555 --> 00:06:30.144
They'll start to move the peritendin over the tendon repeatedly and that's why they get worse the longer they go.
00:06:30.185 --> 00:06:38.817
So we want to put all of their story together, which is why listening and really paying attention to the detail and the subjective is so important.
00:06:39.177 --> 00:06:41.035
So yes, it's Very local.
00:06:41.055 --> 00:06:44.218
Our lovely exception would be our glute med.
00:06:44.259 --> 00:06:56.095
Our older women with gluteal tendinopathy or gluteal bursitis, that compressive issue, because of all the bursa, they get referral down the leg.
00:06:56.134 --> 00:06:58.759
That's very common, but usually not past the knee.
00:06:59.298 --> 00:07:01.341
That's...
00:07:01.538 --> 00:07:10.757
We're going to go deeper into tendinopathy, but just quickly, I want to know what do you do differently for the peritendin versus the tendinopathy which we're about to get into?
00:07:11.170 --> 00:07:11.449
Yep.
00:07:11.911 --> 00:07:20.798
So if we're thinking of a peritendin, actually, if we're thinking of any condition associated, the first thing for me is recognizing and removing our provocative load.
00:07:20.838 --> 00:07:23.259
Now for the peritendin, that's movement.
00:07:23.961 --> 00:07:37.213
And the reason why it's an important one to differentiate is I can't give these people calf raises because it's movement, but someone with a mid portion or an insertional Achilles, calf raises is a fantastic start point and it's critical.
00:07:37.233 --> 00:07:49.086
So what I do differently for the peritendin is we have some strategies for reducing the irritation of that peritendin, but they have to go hand in hand with reducing the movement.
00:07:49.565 --> 00:07:53.331
So if that person is cycling, they need to stop cycling.
00:07:53.350 --> 00:08:01.220
If they're just walking around, you might consider getting them in a shoe with a higher heel so they don't go through as much range of motion while they're walking.
00:08:01.240 --> 00:08:04.444
So it these different strategies.
00:08:04.545 --> 00:08:09.632
And a few years ago, I would have said that you could try isometrics to try and keep them going.
00:08:09.713 --> 00:08:10.394
They hate it.
00:08:10.494 --> 00:08:12.235
It bunches up the peritendin.
00:08:12.276 --> 00:08:15.180
They hate you.
00:08:15.540 --> 00:08:15.961
Don't do it.
00:08:16.983 --> 00:08:17.504
Good info.
00:08:17.543 --> 00:08:18.846
That was a selfish question.
00:08:18.886 --> 00:08:20.548
I'm going to get into the tendinopathy.
00:08:20.608 --> 00:08:29.490
So what's the research currently telling us about isometrics, eccentrics, and HSR, heavy slow resistance.
00:08:29.750 --> 00:08:31.391
Where are you leaning to?
00:08:32.312 --> 00:08:39.719
Yeah, what I'd like everyone to really take away is that I want everyone to be evidence-based, but not recipe-driven.
00:08:39.759 --> 00:08:45.403
You will never be able to go to the research and take the protocol for every patient.
00:08:45.884 --> 00:08:47.905
So do all of those things have a role?
00:08:47.926 --> 00:08:48.986
Of course they do.
00:08:49.006 --> 00:09:09.027
And clinically, you work out what combination you might use, but you could never Never just give someone an isometric exercise and expect that you've restored their strength and their strength endurance and their capacity and their energy storage and made them tolerant to compression and that whole continuum.
00:09:09.067 --> 00:09:12.629
And same with eccentrics, same with heavy, slow resistance.
00:09:13.191 --> 00:09:18.456
If we're thinking about tendons of being a spring, we need the base.
00:09:18.755 --> 00:09:20.477
We need excellent tendons.
00:09:20.706 --> 00:09:26.972
strength and capacity in our muscles so that we have a really strong scaffold for our tendon to work off.
00:09:27.774 --> 00:09:31.256
But then we actually need to sort of sneak up on the tendon.
00:09:31.297 --> 00:09:32.479
Tendons hate change.
00:09:32.918 --> 00:09:34.640
So it would need to be very progressive.
00:09:35.302 --> 00:09:38.806
So to answer your question, it will never be one or the other.
00:09:38.846 --> 00:09:46.673
What I'd like everyone to do is work out how each bit of research can be integrated to build on their toolkit.
00:09:47.434 --> 00:09:50.097
Because those things are part of our toolkit.
00:09:50.754 --> 00:09:56.119
And as physios, it's our clinical reasoning to work out when to use them.
00:09:56.438 --> 00:09:59.240
So to give you an example, I love heavy, slow resistance.
00:09:59.360 --> 00:10:02.124
I use it, but I don't use the protocol that was published.
00:10:02.423 --> 00:10:03.164
And I'll tell you why.
00:10:03.184 --> 00:10:04.466
It was double leg.
00:10:05.145 --> 00:10:10.890
And we know from previous research that people with unilateral tendinopathy have asymmetries.
00:10:11.392 --> 00:10:15.716
So if I'm giving a double leg protocol, I'm actually not addressing those asymmetries.
00:10:16.135 --> 00:10:31.585
So what I want to do is take the previous research about differences in symptomatic and asymptomatic sides, layer in, you know, heavy slow resistance, but actually combine them rather than throwing out everything that's been done before.
00:10:31.625 --> 00:10:33.227
And it's the same with isometrics.
00:10:33.389 --> 00:10:43.163
I would not say that that replaces everything any of your rehabilitation, it's a tool that you might use as a way in, particularly for people if they're a bit fearful about doing something.
00:10:43.202 --> 00:10:46.326
It's a really safe load to start with.
00:10:46.407 --> 00:10:49.291
So it can be really good for their confidence and their self-efficacy.
00:10:49.591 --> 00:10:50.631
But is that all you should do?
00:10:50.672 --> 00:10:51.953
Oh my gosh, no.
00:10:53.576 --> 00:10:53.936
I love that.
00:10:54.177 --> 00:10:58.042
I'm an average physio with a bias towards strengthening.
00:10:58.081 --> 00:11:04.529
So I want you to tell me if I'm oversimplifying this because I think you'll have some pearls.
00:11:05.282 --> 00:11:12.052
I used to base it on irritability or aggravating the patient.
00:11:12.192 --> 00:11:15.296
So if someone was highly irritable, I would start with isometrics.
00:11:15.416 --> 00:11:22.605
If someone wasn't that irritable and I was confident it was tendinopathy, I would bias to go to eccentrics or HSR.
00:11:23.206 --> 00:11:26.711
Can you tell me what's wrong with that thought pattern or is there anything right with it?
00:11:26.952 --> 00:11:27.594
Hit me with that.
00:11:28.514 --> 00:11:36.067
Yeah, I think it's really good that you're being thoughtful about the person in front of you and how you'll sort of shape those decisions.
00:11:36.708 --> 00:11:44.243
So the key thing for me is we need to work out what the deficits are for the person and what their goals are.
00:11:44.683 --> 00:11:52.076
And Jill Cook and Sean Docking did this beautifully a few years ago in editorial, which talked about current capacity and goals.
00:11:52.610 --> 00:11:55.097
Because then what you can do is break down each of those steps.
00:11:55.578 --> 00:12:01.999
So the decision to start with isometrics or isotronics at the start, both of those are safe loads for tendons.
00:12:02.440 --> 00:12:07.907
If it's slow or it's static, then by definition, if it's a tendinopathy, you're laughing.
00:12:08.527 --> 00:12:16.556
Again, contrast that with something like the patellofemoral joint where a heavy isometric leg extension actually might provoke them.
00:12:17.797 --> 00:12:22.461
So again, it can actually help you with your differential and your clinical decision making.
00:12:24.364 --> 00:12:29.929
So in terms of where to start, it can be based on a lot of things.
00:12:29.970 --> 00:12:43.236
I had an ultra marathon runner who had seen a lot of a lot of physios and been given a lot of different advice, had a lot of interventions and he could do six calf raises.
00:12:43.258 --> 00:12:46.381
Now, he wants to run 160 kilometers.
00:12:46.422 --> 00:12:48.845
So, we didn't start with isometrics.
00:12:48.985 --> 00:12:50.105
We just got going.
00:12:50.145 --> 00:12:54.272
Actually, pain wasn't a big feature because he was so unloaded.
00:12:54.312 --> 00:12:55.452
He needed load.
00:12:55.493 --> 00:12:57.475
So, we started with strength endurance.
00:12:57.535 --> 00:12:58.957
We started with strength in the gym.
00:12:59.649 --> 00:13:09.089
So I think there's no right or wrong answer as long as people are thoughtful about what they start with and that they are addressing that person's individual deficits.
00:13:10.491 --> 00:13:11.453
Tell me I'm wrong, Ebony.
00:13:11.474 --> 00:13:12.174
It's okay.
00:13:12.215 --> 00:13:20.230
But it sounds like the better measure is like what their goal is and what their previous capacity was rather than what I was saying about irritability.
00:13:20.532 --> 00:13:21.453
Would that be about right?
00:13:21.761 --> 00:13:28.652
It can be, but irritability can definitely feed in, particularly if they are anxious.
00:13:29.312 --> 00:13:55.653
And a really irritable tendon or a person with a really irritable tendon will need a lot of education around if you have pain with exercise and I'm giving you an exercise, but I haven't dealt with the fact that these are safe loads and teaching people about what is the provocative load and what is the safe load, then people may not be adherent.
00:13:55.735 --> 00:14:05.563
So as David Butler would say, just meeting people at their story and really making sure they understand what what is safe to do.
00:14:05.625 --> 00:14:06.245
Yeah.
00:14:06.306 --> 00:14:13.879
But I'm less concerned with irritability, particularly early, because you're not giving high tendon load.
00:14:14.058 --> 00:14:17.605
You're removing that load, but just teaching people when to listen.
00:14:17.686 --> 00:14:19.729
So to listen 24 hours after the load.
00:14:20.892 --> 00:14:23.635
There's a study that's coming back to me talking about irritability.
00:14:23.736 --> 00:14:26.380
I believe it was on jumper's knee and it was volleyball players.
00:14:26.421 --> 00:14:34.917
So athletes that are experienced with loading, And I think they pushed into pain and did quite aggressive exercises and found they had a better outcome.
00:14:35.258 --> 00:14:36.419
Is that coming to mind for you?
00:14:36.461 --> 00:14:45.558
There's a couple of different studies that have looked at whether or not it's okay to push into pain.
00:14:45.698 --> 00:14:53.413
And in fact, the original eccentric work was almost based on progressing pain trying to get people to that level.
00:14:54.215 --> 00:14:56.398
So again, I think it's really individual.
00:14:58.280 --> 00:15:04.730
This is why I never like giving a number because for some people, five out of 10 pain, they always play with it.
00:15:04.791 --> 00:15:05.793
It's just not an issue.
00:15:05.832 --> 00:15:09.038
For some people, five out of 10 pain is completely unacceptable.
00:15:09.057 --> 00:15:13.524
So we talk about symptoms that are low and stable.
00:15:14.046 --> 00:15:18.432
So what I'm looking for is increasing our load while...
00:15:19.937 --> 00:15:24.063
people can maintain or reduce their 24-hour pain.
00:15:24.104 --> 00:15:25.785
So their symptoms are low and stable.
00:15:26.106 --> 00:15:27.609
So that doesn't need to be zero.
00:15:27.688 --> 00:15:30.732
And again, that's a really important education point for people.
00:15:31.033 --> 00:15:33.336
You're trying to aim for low and stable symptoms.
00:15:33.996 --> 00:15:35.139
Yeah, yeah, I like that.
00:15:35.600 --> 00:15:42.149
The question I was going to ask you, which I think you've answered, but I reckon you've got a bit more there.
00:15:42.489 --> 00:15:48.817
What's really changed for you in the last three to five years with what you've learned and what you've studied?
00:15:49.250 --> 00:15:51.381
How has that actually changed your clinical practice?
00:15:52.287 --> 00:15:53.895
Oh, I'm going to have to say the brain here.
00:15:53.936 --> 00:16:01.414
So, um, a much better understanding of pain, thanks to particularly Laura Mimosley and David Butler.
00:16:01.434 --> 00:16:04.717
So pain is produced by the brain 100% of the time.
00:16:04.778 --> 00:16:12.244
That doesn't matter if it's a paper cut, chronic low back pain or tendinopathy, your brain will produce pain to protect you.
00:16:12.264 --> 00:16:18.350
And in the case of tendons, that's quite useful because it tries to stop us overloading and doing really silly things.
00:16:20.370 --> 00:16:38.275
The other thing for me is the changes around the motor cortex and how we might need to in some of those principles into our rehabilitation to really improve our outcomes for people with tendinopathy, that it isn't just about tendon load and muscle load and kinetic chain.
00:16:38.316 --> 00:16:42.562
We actually need to appreciate the spinal cord and brain and just how complex it is.
00:16:42.582 --> 00:16:42.602
I
00:16:44.404 --> 00:16:44.725
love that.
00:16:44.765 --> 00:16:52.158
And that's, we're talking more chronic pain, persistent pain strategy, which we might use rather than just considering the tendon.
00:16:53.697 --> 00:16:53.999
Yep.
00:16:54.158 --> 00:17:05.257
And critical to that would be that we shouldn't reserve things like education only if we think we're dealing with chronic pain.
00:17:05.297 --> 00:17:09.463
Everyone deserves that respective language and that education.
00:17:09.483 --> 00:17:12.970
And a good example would be something like tendonitis.
00:17:13.490 --> 00:17:16.896
If people are using terms like tendonitis, their underlying...
00:17:18.018 --> 00:17:33.057
understanding of the condition is that it's inflammatory and you will probably not be able to convince them to do exercise because their understanding of what they need to do for that condition is likely based on rest, ice, anti-inflammatories.
00:17:33.497 --> 00:17:42.423
So just making sure our biopsychosocial-ness actually translates across every aspect of patient care.
00:17:42.443 --> 00:17:49.212
So the terminology we use, how we empower them so that it all marries up.
00:17:49.614 --> 00:18:02.290
If people are saying things like tendonitis and then we're giving exercise, we're probably doing them a disservice about really educating them about their body and their condition.
00:18:04.153 --> 00:18:10.000
Ebony, I think that would be a wonderful second chat with you about the central changes in tendonitis.
00:18:10.561 --> 00:18:11.526
But for now, I think...
00:18:11.546 --> 00:18:11.787
You did
00:18:11.826 --> 00:18:13.071
not say tendinitis.
00:18:13.252 --> 00:18:14.036
Tendinitis
00:18:14.237 --> 00:18:15.181
means it's inflamed.
00:18:15.382 --> 00:18:18.855
I can't believe I just said that after you just went on that rant.
00:18:19.759 --> 00:18:20.080
And so...
00:18:21.569 --> 00:18:25.673
I was even in this discussion about would it matter if therapists use that?
00:18:25.713 --> 00:18:27.095
But I love how you outlined that.
00:18:27.315 --> 00:18:30.698
If therapists are using it, patients are probably thinking it's inflammation.
00:18:30.978 --> 00:18:31.898
And then what do you reckon?
00:18:31.959 --> 00:18:32.118
They're
00:18:32.138 --> 00:18:32.459
Googling.
00:18:32.499 --> 00:18:33.840
Absolutely.
00:18:34.320 --> 00:18:36.083
And in fact, we're just starting a study on that.
00:18:36.442 --> 00:18:39.665
But the key thing, so there's actually a great paper by Nickel.
00:18:39.746 --> 00:18:40.946
It's a systematic review.
00:18:41.146 --> 00:18:47.451
And they looked at the impact of terminology on what people thought they needed to do about the condition.
00:18:47.491 --> 00:18:56.721
And these vast differences, even in terms of fracture, if you're saying crack in the bone versus broken bone as to whether or not people think they need a cast.
00:18:58.063 --> 00:18:59.904
Language is so important.
00:19:00.066 --> 00:19:01.686
I love that you've brought that up.
00:19:01.847 --> 00:19:02.769
Thank you so much.
00:19:04.250 --> 00:19:08.414
Well, I think that summary you just gave us is a great place to end it.
00:19:08.535 --> 00:19:10.136
So I'll leave it there.
00:19:10.196 --> 00:19:12.219
And thank you so much for your time today, Ebony.
00:19:12.799 --> 00:19:13.980
Oh, thanks so much for having me.
00:19:14.020 --> 00:19:14.942
Thank you.
