Thank you.
SPEAKER_02:When you're going through your progressive load test, people with a peritendin condition will be provoked during the movement phase. So your single leg calf raises, your double leg calf raises. Whereas people with a tendinopathy won't because that's not a spring exercise. It's not high rate of loading. Once you get to the jumps and the hops, someone with a peritendin condition might have no pain if they don't go through any range or they might have minimal pain. They'll have a more diffuse location compared to your tendinopathy. Thank you.
SPEAKER_01:Differential diagnosis between the Achilles tendon and the paratendon unit can be quite tricky. Today, we have the pleasure of welcoming back Ebony Rio from La Trobe Uni. Now, Ebony's done her PhD in tendon pain and she's worked for some wonderful people like the AIS and the Australian Ballet Company. Ebony's done a physio network practical, which you can try for free over in the show notes. I would highly recommend doing this with your physio teams or your allied health teams. Really wonderful resource to upskill. Please enjoy this episode My name is Michael Risk and this is Physio Explained. Welcome, Ebony. Thank you for joining us.
SPEAKER_02:Thank you so much for having me. I'm excited to talk to you again.
SPEAKER_01:You've done a practical on Achilles in-season management versus rehab management and how to do differentials. And you just listed off about nine differentials. So if we start there, how would you approach... an athlete that's got Achilles tendinopathy or pain in the back of the heel, what are some things you might be asking to look out for to differentiate between is this Achilles and all the other things it could be?
SPEAKER_02:Nice. So, I think the first thing to think about is I love the way you framed it. So, take a step back and think, okay, this athlete has pain in the back of the heel. Let's think of all the structures that might be involved and let's really hone into what they're saying. So, what we might start with is we might ask them where their pain is. But we've done some research that shows that when you ask someone where their pain is and then you take them through a load test, that's actually different. So, it's not enough to just say, where's your pain while they're sitting in the chair or We're going to take that on board as part of the information in the subjective, but we're going to then test that hypothesis when we're doing the objective assessment. The reason we ask them where their pain is, is some of these different clinical presentations have quite specific pain patterns. And we also ask them what activities aggravate their pain. And that's again, because some of these tissues have particular pain behaviors. So let's go through that. We know that Achilles tendons behave like a spring. So when you do something fast, spring-like... that's high tensile load. If we're talking down at the insertion, you can always also have compression of that tendon as they go into dorsiflexion. So the two loads you really want to hear when someone's talking about the Achilles tendon is you want to hear high tensile load, you want to hear high spring type load. So it hurts when I run, if it's Achilles insertion, it hurts when I do fast change of direction. So that's a combination load. So they'll also give you quite specific pain location. So the mid portion they tend to pinch with two fingers and the insertion they tend to point down on the insertion with one finger. So that's how we use our combination of pain location and loads. But if we contrast that with something like a peritendin, so you're going to get some clues with a peritendin. They'll be talking about shear and friction loads. So these will be the athletes that will say to you, it hurts when I cycle. It hurts when I'm on the rower or it hurts when I swim. So this is when the peritendin layers, so those synovial layers are shearing over the Achilles tendon, but they're not using their Achilles tendon like a spring. And there's one more little sneaky one that might get people. Tendons warm up. With a peritendin, they get worse the longer they go. So if you have a runner, don't be fooled. The runner might say, yes, it hurts when I run, but you really want to listen to pain behavior. because a tendinopathy will warm up, whereas a peritendinitis will get worse. And what's going on there is when they start running, they can sort of maintain their function. And then as they fatigue, they start to go through bigger ranges of motion and they overload the peritendin. So we want to ask about pain location, what loads provoke and pain behavior, because that will help differentiate tendon and peritendin. They're the most common things going on the back of the ankle. If it doesn't fit either of those, that's when you need to start to think of plantaris, sural nerve, calcaneal bursa, and those posterior ankle impingement, FHL.
SPEAKER_01:They still sound quite specific to me. So like the pointing to the bottom of the heel versus the pinching of the mid, and then a pattern as they move and what they're doing as the movement. Those last three or four differentials that you mentioned, do they tend to be more vague or just like, hmm, that doesn't really fit those two?
SPEAKER_02:It's a good question. It doesn't fit those two in terms of the location and the pain behavior. So that's when you start to have your antenna up that there's something else going on and you'll move to kind of test that. So the way I explain it in the practical is you want to leave the subjective with a primary hypothesis that you're going to test and you're actually looking to prove yourself wrong. That's what you're trying to do. So you've got your N of one research person in front of you and you're trying to prove that it's not Achilles tendinopathy. So you want to test everything else. So what we might do for FHL, so FHL is seen in most commonly our dancers and it's a condition of the peritendin because they go from big ranges of grand plie through point and they'll have crepitus around that medial malleolus and they'll be provoked when you do resisted FHL testing. So that would rule in the FHL. For the posterior ankle impingement, we pop our athlete or our patient in prone. We basically do a plantar flexion overpressure and you can feel through inversion and eversion and that tests posterior impingement really nicely. But you'll also get a little bit of that in your clinical testing because someone with insertional Achilles is really happy in full plantar flexion, whereas someone with posterior impingement has pain at the top of their rise. So even asking people during your clinical testing at what point they have pain, just the devil's in the detail.
SPEAKER_01:I just imagined listening to this five minutes back and pausing and doing each of those things would be such a valuable exercise. And also that's what you did in the practical. So this is so helpful already. I'm branching out here. Take me to treatment differences between peritendin because I'm seeing so much more coverage about peritendin and us missing it and treating it like an Achilles tendon. Take me to the treatment differences there or what we should be looking for as clinicians in the early phases.
SPEAKER_02:Yeah, nice. So just to really wrap up, because people get these mixed up and in research, they're often conflated and that's a disaster because they're different. So you're going to get some clues in your subjective history. When you're going through your progressive low test, people with a peritendic condition will be provoked during the movement phase. So your single leg calf raises, your double leg calf raises. Whereas people with a tendinopathy won't because that's not a spring exercise. It's not high rate of loading. Once you get to the jumps and the hops, someone with a peritendin condition might have no pain if they don't go through any range or they might have minimal pain. They'll have a more diffuse location compared to your tendinopathy. But the reason why all that's important is if someone has Achilles tendinopathy, either insertional or mid-portion, it's really important that we're completing calf loading. through range calf loading. So with and without weight, depending on where they're at, but a calf rise. Whereas for someone with peritendinitis, a calf rise, that movement is their provocative load. So we actually can't start someone with a peritendin irritation with calf rises. Now you might hear peritinon, tenosynodium. Peritendin is like the umbrella term because lots of different tendons in the body have different So I know your layers that go over them. So they've got a whole heap of names, but just remember peritendin as the outside sort of sheath. So the differences in your start point and your advice for a peritendin and a tendinopathy, I'll summarize it for you. Someone with a peritendin, you can start them on something like stairs where they're walking up and down stairs, keeping their heel up. It's sort of quasi-isometric because you don't want them to drop. But what you're not doing is a sustained isometric. They hate those. It bunches up the peritendent and they're worse. But someone with tendinopathy, you're going to get them going on concentric eccentric from day one because that is a slow load. It's a completely safe start load. my progression for someone with a peritendin is to progress the range of motion that they go through. Eventually, I'll need to get them to a full range calf raise to address their kind of underlying deficit, like the reason why they got them into trouble in the first place. But do you see why I can't start with a calf raise?
SPEAKER_01:And it would be a very common mistake. I imagine you might have someone like four to six weeks in hammering calf raises and then they go for a second opinion and it was a peritendin all along.
SPEAKER_02:Yeah, that's super common. So, I am always intrigued when our patients and athletes are not adherent because I think that's actually really useful information. If someone didn't do their exercises, is it because it made them worse? Because that tells you so much. If you give someone with Achilles tendinopathy single leg calf raises and they come back worse, that is super helpful clinically for you because you think, okay, what is provoked? by movement, by shear and friction loads. It's not the tendon itself. It's not the tendon proper. It's likely to be those outside layers or it might be the FHL, but it's definitely relating to range of motion and movement as opposed to spring. So, you're right. It's missed all the time and it's a really satisfying one to pick up clinically because we can give so many tips and they can coexist. And if they do, manage the peritendin first and then worry about the tendinopathy.
UNKNOWN:you
SPEAKER_00:Thank you. Thank you.
SPEAKER_01:My brain went two places. I'm having flashbacks to 13 years ago and how many of these I've probably missed as a grad when I hadn't heard about peritendin because it feels like it's really come through in the last five to seven years. And
SPEAKER_02:there's so little research on it because it's super hard to sort of recruit for. So I see quite a few clinically because I see the ones that don't get better, but it would be a slightly nightmarish PhD. We're trying to do a little bit of research in it, but super tricky. Yeah.
SPEAKER_01:Is there any imaging that distinguishes or is it too close and you can't see it?
SPEAKER_02:You know, you can often see on MRI or ultrasound like a halo. So you can see the fluid and the inflammation. So if you look around, you'll see a ring around the tendon. If it's the plantaris on the medial side, frictioning against the Achilles. You can often see fluid between the plantaris and the Achilles on that medial side. So you can see it. So you either need to be super confident with reading imaging or have a really good doc or radiologist that can confidently call it. The other really helpful clinical diagnostic tool that we use is from Dr. Andrew Garnham. If you get a stethoscope, so if you go and find your third year cardiology prac stethoscope that you've not picked up, If you put it on a tendon like the Achilles or FHL or tippost or even in the upper limb, de Quervain's or intersection syndrome, because they're all so superficial. If you get the person to plantar flex and dorsiflex, you can hear the crepitus and it's far more sensitive than just feeling. At uni, we learnt to sort of feel the tendon and you can miss it. So it's good, not just diagnostically, but even as a monitoring tool, like how am I going to move this person on from stairs into some small range calf raises into a full range calf raise? And rather than just cross my fingers, know that they're sort of ready for that progression.
SPEAKER_01:Just imagining that ASMR channels with someone's Achilles, they're putting the mic up there. Brilliant. We wanted to cover a little bit of in-season work that you would do with athletes and versus the rehab and how that might look different. How do you see that?
SPEAKER_02:Yeah. So we rehabilitate athletes and we have to manage them in season. So let's sort of define what we mean by that. When I'm talking about in-season management, your athlete, whether they're recreational or elite, they are competing. So they're playing, they're training. You might have very little influence over their loading. You might be able to negotiate some volume at training, but essentially they're in the thick of it. What that means is they're getting plenty of tensile loading plus or minus compression. They do not need additional plyometrics. They do not need energy storage and release. They don't need all of the end stage rehabilitation. So you can't rehabilitate a tendon in season because they're already getting high loads. Now, the Visner study in 2005 showed that even adding eccentric exercises to which has been used in rehabilitation in season, made patellar tendons worse. So we can't just take research from rehab and chuck it in season because they don't do well. So what we want to do is say, okay, they're getting plenty of tendon loading. What we can do is safely apply isometric and isotonic loading. Now, isotonic loading for me, the concentric eccentric is critical. If the athletes like the isometrics, great, but they really need that through range loading. For the Achilles, that's going to mean seated calf, standing calf, both single leg, endurance, and potentially even some weight transfers if they're missing the top height. So someone might have quite a few calf raises or calf exercises in season. You want to negotiate, if you can, time between high tendon load. So they might train Tuesday, Thursday, play Saturday. That means on their gym days, your Monday, Wednesday, Friday, they're that you don't need any additional high tendon load. So don't let them do skipping for a warmup or box jumps or plyometrics. Because what that'll mean is they'll be actually doing six or seven days a week of high tendon load. So look out for the sneaky load, which is often in a warmup. If we're talking about what we do add, we add isometrics and isotonics, and then we wait to the end of the season, and then we can think about rehabilitation. Rehabilitation is removing provocative load. So, taking them off, you know, running if they're quite irritable and actually taking them through the four stages of restoring their strength capacity and rebuilding their spring. So, stage one and two, in-season rehab. Stage one to four, your full rehabilitation.
SPEAKER_01:It's a great lesson there. I'm thinking about the conversations with my younger physios and having patients while someone's in season. And A frustration that I experienced and some younger physios as well, I imagine, is that while they're in season, we're maybe not progressing or feeling like we're progressing this loading. But I guess what you're saying there and the research is saying is it's okay, a level of maintenance and always framing up for the patient that the real progress is probably going to happen in the off season.
SPEAKER_02:And spot on knowing what is a win. So what is a win in season? Low and stable symptoms, but being able to perform. They may not be pain-free. So framing that up is critical so that everyone's on the same page. The other thing to make sure everyone's on the same page about is what is high tendon load. High tendon load is speed, not heavy. Tendons love being in the gym. Don't take them out of the gym. Keep them going on their slow, heavy load. they'll be better for it. If you try and sort of rest them and wrap them in cotton wool, they'll get progressively more dysfunctional, weak, whatever term we'd like to use, and they actually get more symptomatic. So that expectation management is critical.
SPEAKER_01:Thank you so much, Ebony. That was awesome. You covered it all. I took so many notes here. Thanks so much for your time.
SPEAKER_02:Thank you for having me.
SPEAKER_01:A wonderful episode by Ebony. Now, just a reminder, you can head over to the show notes and try the Physio Network Practicals for free. So head over there, click the link and please enjoy the practical content. A quick note from me, I actually did my very first PhysioExplained podcast with Ebony and this will be my very last as host. It's been an absolute privilege sharing the microphone with some of our field's greatest minds. I've tried to keep it brief, bring you as much value and ask some questions that elicit some really great responses. This has been my version of giving back to our profession. I think we're at a turning point for our profession and I genuinely believe we have a wonderful profession. So thank you so much for sharing your ears with me and I hope I've done my part to help you and give back to this wonderful profession. If you want to follow any more of my journey, you can find me at that.physioguy on Instagram or follow iMove Physiotherapy for our clinics.