Talking Tendons

Patients often ask about dietary supplements and if they may be helpful in recovering from a tendinopathy problem. There is a new systematic review out which has attempted to answer this question and it is the subject of this episode of talking tendons. I hope you enjoy.    Here is the reference Qiu, F., Li, J. and Legerlotz, K., 2022. Does Additional Dietary Supplementation Improve Physiotherapeutic Treatment Outcome in Tendinopathy? A Systematic Review and Meta-Analysis. Journal of clinical medicine, 11(6), p.1666.   And links to upcoming Mastering Lower Limb Tendinopathy course in Australia https://www.eventbrite.com/cc/mastering-lower-limb-tendinopathy-live-australia-211689See omnystudio.com/listener for privacy information.

Will midportion Achilles pain improve if you wait and see? This is often a really important question to discuss with patients. Luckily we have some evidence to answer it which I explore in this short podcast (9 minutes). Hope you enjoy.  Here are the related studies 1/ Horstmann, T., Jud, H.M., Fröhlich, V., Mündermann, A. and Grau, S., 2013. Whole-body vibration versus eccentric training or a wait-and-see approach for chronic Achilles tendinopathy: a randomized clinical trial. journal of orthopaedic & sports physical therapy, 43(11), pp.794-803. 2/ Rompe, J.D., Nafe, B., Furia, J.P. and Maffulli, N., 2007. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. The American journal of sports medicine, 35(3), pp.374-383. 3/ de Vos, R.J., van der Vlist, A.C., Zwerver, J., Meuffels, D.E., Smithuis, F., van Ingen, R., van der Giesen, F., Visser, E., Balemans, A., Pols, M. and Veen, N., 2021. Dutch multidisciplinary guideline on Achilles tendinopathy. British journal of sports medicine, 55(20), pp.1125-1134.See omnystudio.com/listener for privacy information.

This week I talk about a feasibility cohort study which sought to determine whether a larger cohort study addressing this question would be feasible. Listen to hear some interesting preliminary findings.  Merza, E.Y., Pearson, S.J., Mallows, A.J. and Malliaras, P., 2023. The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study. Physical Therapy in Sport.Mallows, A., Jackson, J., Littlewood, C. and Debenham, J., 2020. The association of working alliance, outcome expectation, adherence and self‐efficacy with clinical outcomes for Achilles tendinopathy: A feasibility cohort study (the MAP study). Musculoskeletal Care, 18(2), pp.169-176.See omnystudio.com/listener for privacy information.

We have known for a while that type of exercise intervention (e.g. intensity, frequency, etc) does not seem to influence self-reported outcomes such as pain. Maybe all the benefits from exercise are explained by non-specific effects, or maybe exercise has benefits that do not depend on the type of exercise. In this episode, I discuss 3 studies that look into (at least partly) other benefits that we may see at the level of the muscle and tendon from higher-load exercise interventions.  References: Radovanović, G., Kunz, J., Bohm, S., Arampatzis, A. and Legerlotz, K., 2021. Reliable and effective novel home-based training set-up for application of an evidence-based high-loading stimulus to improve triceps surae function. Journal of Sports Sciences, 39(24), pp.2786-2795. Radovanović, G., Bohm, S., Peper, K.K., Arampatzis, A. and Legerlotz, K., 2022. Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial. Sports Medicine-Open, 8(1), pp.1-19. Radovanović, G., Bohm, S., Arampatzis, A. and Legerlotz, K., 2023. In Achilles Tendinopathy the Symptomatic Tendon Differs from the Asymptomatic Tendon While Exercise Therapy Has Little Effect on Asymmetries—An Ancillary Analysis of Data from a Controlled Clinical Trial. Journal of Clinical Medicine, 12(3),See omnystudio.com/listener for privacy information.

This week, I had an engaging conversation with Anthony Nasser, an up-and-coming researcher on tendinopathy who recently completed his PhD on proximal hamstring tendinopathy. Our discussion covered the reasons for the lack of research attention towards this condition, the current state of evidence, and insights from his doctoral studies. You can find the full conversation here.Here are Anthony's related publications: Nasser, A.M., Pizzari, T., Grimaldi, A., Vicenzino, B., Rio, E. and Semciw, A.I., 2021. Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention. Physical Therapy in Sport, 48, pp.67-75. Nasser, A.M., Vicenzino, B., Grimaldi, A., Anderson, J. and Semciw, A.I., 2021. Proximal hamstring tendinopathy: a systematic review of interventions. International journal of sports physical therapy, 16(2), p.288. Nasser, A., Semciw, A., Grimaldi, A., Rio, E., Pizzari, T. and Vicenzino, B., 2022. Core outcome set development for proximal hamstring tendinopathy (COS-PHT): a study protocol. Physical Therapy Reviews, 27(4), pp.313-319.    See omnystudio.com/listener for privacy information.

Palpation can be useful for the diagnosis and assessment of tendinopathy, but there are limits. This is because non-painful tendons can be tender, and tenderness in painful tendons seems to be very slow to get better.  Link to Evidence for Improvement in Local but not Diffuse Pressure Pain Thresholds Following Physical Therapist Interventions for Tendinopathy: A Systematic Review Link to  Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball playersSee omnystudio.com/listener for privacy information.

Interesting perspective paper from Arampatzis et al talking about how we should consider tuning of muscle tendon unit in terms of muscle strength and tendon stiffness when considering training for specific groups. See omnystudio.com/listener for privacy information.

This talking tendons episode will discuss a study by Igor Sancho, PhD, assessing Achilles forces during common rehab exercises and habitual activities and how this relates to reported pain among runners. Some interesting implications for practice. Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory studySee omnystudio.com/listener for privacy information.

In this episode, I am discussing kinesiophobia in the context of tendon rehab and how rehab can be conceptualised as graded exposure for some people.  References 1) Physiotherapy management of Achilles tendinopathySee omnystudio.com/listener for privacy information.

In this episode, I talk about load test pain assessment and how this can also be used to assess kinesiophobia and movement apprehension.  References 1) Physiotherapy management of Achilles tendinopathy: https://pubmed.ncbi.nlm.nih.gov/36274038/ 2) Kinesiophobia Severity Categories and Clinically Meaningful Symptom Change in Persons With Achilles Tendinopathy in a Cross-Sectional Study: Implications for Assessment and Willingness to Exercise: https://pubmed.ncbi.nlm.nih.gov/35295417/See omnystudio.com/listener for privacy information.

This is an interesting study from the Delaware tendinopathy group among others investigating a host of structural, tissue property, functional and pain factors that may persist among people with Achilles tendinopathy making a return to running. Provides guidance to clinicians about potential impairments to consider assessing.  Here's the link to the study: Corrigan, P., Hornsby, S., Pohlig, R.T., Willy, R.W., Cortes, D.H. and Silbernagel, K.G., 2022. Tendon loading in runners with Achilles tendinopathy: Relations to pain, structure, and function during return‐to‐sport. Scandinavian Journal of Medicine & Science in Sports. Here's the link to my upcoming course series in the UK in Sept: https://www.eventbrite.com/cc/mastering-lower-limb-tendinopathy-uk-sept-2022-670009See omnystudio.com/listener for privacy information.

In this episode I talk about three qualitative studies that aim to understand the patient perspective and patient motivations in Achilles tendinopathy. I find this work really helps clinicians to understand what patients are gong through so we are able to be empathic and help them. Hope you enjoy! Here's a link to courses in the UK: https://www.eventbrite.com/cc/mastering-lower-limb-tendinopathy-uk-sept-2022-670009 Here are the studies: Turner, J., Malliaras, P., Goulis, J. and Mc Auliffe, S., 2020. “It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy. PloS one, 15(5), p.e0233459. Mc Auliffe, S., Synott, A., Casey, H., Mc Creesh, K., Purtill, H. and O'Sullivan, K., 2017. Beyond the tendon: experiences and perceptions of people with persistent Achilles tendinopathy. Musculoskeletal Science and Practice, 29, pp.108-114. Mallows, A., Head, J., Goom, T., Malliaras, P., O'Neill, S. and Smith, B., 2021. Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: A qualitative study. Musculoskeletal Science and Practice, 56, p.102450.See omnystudio.com/listener for privacy information.

This paper is more than 30 years old but it is a beauty. Farley et al talk about human preferred hopping frequency and how it relates to metabolic cost and how fast muscles are contracting, and also how our instructions can influence how well people hop (and the mechanisms that drive this). Important to consider hopping instruction when assessing submaximal hopping in the clinic.  Here's a link to the paper Farley, C.T., Blickhan, R., Saito, J. and Taylor, C.R., 1991. Hopping frequency in humans: a test of how springs set stride frequency in bouncing gaits. Journal of applied physiology, 71(6), pp.2127-2132.See omnystudio.com/listener for privacy information.

There is so much debate about the use of steroids for tendinopathy. Opinions vary between 'you should never use steroid as will lead to recurrence, worse pain or rupture' to 'it's fine, do as much steroid as you like'. Opinions dominate as we have limited data. Until now. This is the first trial looking at 2 year outcome for exercise +/- steroid for Achilles tendinopathy. Interesting findings! Here's the link to the study: Johannsen, F., Olesen, J.L., Øhlenschläger, T.F., Lundgaard-Nielsen, M., Cullum, C.K., Jakobsen, A.S., Rathleff, M.S., Magnusson, P.S. and Kjær, M., 2022. Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy: A Randomized Clinical Trial. JAMA Network Open, 5(7), pp.e2219661-e2219661.See omnystudio.com/listener for privacy information.

This is a new and lovely to read randomised trial comparing pain science education (including lots of good biopsychosocial info) versus placebo education for Achilles tendinopathy. Some interesting findings and potential avenues for further study. Definitely worth a listen and read.  Here is a link to the actual paper:  https://journals.lww.com/pain/Abstract/9900/The_effects_of_pain_science_education_plus.122.aspxSee omnystudio.com/listener for privacy information.

This is a new study from my PhD student, Igor Sancho. He looks at strength, psychological and other factors that may be different between health runners and runners with Achilles tendinopathy. Seated calf raise 6RM seems to be the strongest predictor of having Achilles tendinopathy. Some interesting other findings and clinical implications.  Here is a link to this paper, and Igor's other PhD papers: Sancho, I., Morrissey, D., Willy, R.W., Tayfur, A., Lascurain-Aguirrebeña, I., Barton, C. and Malliaras, P., 2022. Recreational runners with Achilles tendinopathy have clinically detectable impairments: A case-control study. Physical Therapy in Sport, 55, pp.241-247. Sancho, I., Malliaras, P., Barton, C., Willy, R.W. and Morrissey, D., 2019. Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis. Gait & posture, 73, pp.189-201. Sancho, I., Morrissey, D., Willy, R.W., Barton, C. and Malliaras, P., 2019. Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: a single cohort feasibility study. Physical Therapy in Sport, 40, pp.107-116. See omnystudio.com/listener for privacy information.

On this episode I focus on a new study from my PhD student Eman Merza. It is a cross-over randomised trial testing the effect of high and low contraction time and high and low intensity isometric contractions on acute changes to tendon volume and stiffness. Some very interesting potential insights for tendon adaptation. Good work, Eman! Hope you enjoy.  Peter Here is a link to the study (open access for a few weeks):  https://journals.biologists.com/jeb/article/225/10/jeb243741/275395See omnystudio.com/listener for privacy information.

Had a lovely chat with Shawn Hanlon who is a PhD candidate about his relatively new paper exploring patient features and clinical characteristics and how they may define certain subgroups of Achilles tendinopathy . Lots more to learn in this field and this is early work, but we discuss some of the juicy potential clinical implications. Hope you enjoy! And here is the link to the paper and also the  1/ Hanlon, S.L., Pohlig, R.T. and Silbernagel, K.G., 2021. Beyond the diagnosis: Using patient characteristics and domains of tendon health to identify latent subgroups of Achilles tendinopathy. journal of orthopaedic & sports physical therapy, 51(9), pp.440-448. 2/ And this is the bumper issue of JOSPT from 2015 that is all about tendinopathy: journal of orthopaedic & sports physical therapy, 45(11) See omnystudio.com/listener for privacy information.

There is lots of debate about the pain mechanisms, particularly if there are central changes, in Achilles and other tendinopathies. Most studies in the literature use proxy measures of central sensitisation like pressure pain threshold away from the painful site, Other measures like conditioned pain modulation have been investigated less frequently. In this episode of talking tendons I discuss a huge new study investigating CPM in Achilles tendinopathy with some interesting findings and implications. Hope you enjoy! Here is the link to the study: Mkumbuzi, N.S., Mafu, T.S., September, A.V., Posthumus, M. and Collins, M., 2021. Conditioned pain modulation is not altered in recreational athletes with Achilles tendinopathy. Translational Sports Medicine, 4(1), pp.147-153.See omnystudio.com/listener for privacy information.

This is one of my favourite narrative expert reviews that discusses the benefits of human biologic springs like the Achilles tendon. These benefits can be summarised as follows:  Metabolic energy conservation Amplification of muscle power output Attenuation of muscle power input Some really interesting mechanisms and insights for rehabilitation . I hope you enjoy! Here is the link to the study: Roberts, T.J. and Azizi, E., 2011. Flexible mechanisms: the diverse roles of biological springs in vertebrate movement. Journal of experimental biology, 214(3), pp.353-361.See omnystudio.com/listener for privacy information.