[Physio Discussed] Are we managing Achilles Tendinopathy the right way? with Dr Ruth Chimenti and Dr Myles Murphy

In this episode, we have a discussion with Myles Murphy and Ruth Chimenti to discuss the topic of Achilles Tendinopathy. We explore:

• Subjective and objective assessment of Achilles tendinopathy
• Traditional assessment tests and differential diagnosis
• Boom-bust cycle in tendinopathy
• Difference in management for acute vs chronic tendinopathy
• Current evidence for treatment of Achilles Tendinopathy
• Gold standard for loading of tendons

👉🏻  Try Masterclass for free for 7 days here now - https://physio.network/mc-murphy-chimenti

A/Prof Myles Murphy is a Sport and Exercise Physiotherapist consulting at SportsMed Subiaco in Perth, Western Australia, as well as the Director of the Centre for Injury Prevention and Pain at the University of Notre Dame Australia. A/Prof Murphy completed his PhD in Achilles tendinopathy and his current research focuses on improving the prevention and management of this chronic musculoskeletal condition.

Dr. Ruth Chimenti, PT, PhD, is an Associate Professor in the Department of Physical Therapy & Rehabilitation Science at the University of Iowa. She completed her PhD in lower extremity biomechanics and then completed postdocs focusing on ultrasound imaging and pain science. Her current research focus on the evaluation and treatment of Achilles tendinopathy and plantar heel pain. 

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 @sarah.yule from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

Introduction

SPEAKER_02 0:04

What are the key clinical signs that help us confidently diagnose Achilles tendinopathy? How should we assess tendon load capacity beyond simply talking about pain? And what does best practice management look like across reactive, degenerative, mid-portion, insertional, running and non-running presentations? On today's episode, I'm joined by Dr. Ruth Cementi and Dr. Miles Murphy to discuss the assessment and management of Achilles tendinopathy. Dr. Ruth Cementi is a physiotherapist and associate professor in the Department of Physical Therapy and Rehabilitation Science at the University of Iowa. Her research focuses on understanding the factors that contribute to pain and disability in foot and ankle conditions and developing more targeted treatment approaches. She has authored more than 60 peer-reviewed publications, led the APTA Clinical Practice Guidelines for Mid-Portion Achilles tendinopathy, and serves as an associate editor at the Journal of Pain. Dr. Miles Murphy is a sport and exercise physiotherapist and clinician researcher based in Perth, Western Australia. His research focuses on the drivers of pain and disability in lower limb musculoskeletal conditions, particularly tendinopathy, alongside novel neuroscience-based interventions. Miles completed his PhD in lower limb tendinopathy in 2022 and has published more than 90 papers and continues to work extensively with athletes in complex tendon presentations. In this episode, we explore Achilles tendinopathy from diagnosis through to return to performance, including how to differentiate it from other causes of posterior heel pain, what to do when patients are highly irritable, and how to manage insertional presentations. You're going to love today's episode. It's filled with some clinical gems. I'm Sarah Yule, and this is Physiodisgust. Welcome to you both. Thank you so much for joining today.

SPEAKER_01 1:55

Thank you so much for having us.

SPEAKER_02 1:58

Let's get straight into it.

Key subjective & objective findings

SPEAKER_02 2:00

In the realms of Achilles tendinopathy, what are the key subjective and objective findings that you find help you confidently diagnose Achilles tendinopathy and differentiate it from other causes of posterior heel pain? Miles, I might throw across to you first.

SPEAKER_01 2:16

Yeah, it's such a great question because I think sometimes if you get pain in and around the Achilles, we lump everything together as Achilles tendinopathy. And you can do that. There's not necessarily anything wrong with that. But I guess when you talk about treatment directions, if you've got a more specific diagnosis as to what the true irritant is to the system, it's a little bit easier to then provide a treatment management plan that is going to give you better results. So I guess for me, when I talk about Achilles tendinopathy, I'm talking about tendon pain, so pain within either the mid portion or the insertional aspect of the tendon that is load dependent. So that is pain that as you do more higher loading tasks, whether that's doing a single versus a double leg heel raise or doing a single leg jump versus a double leg jump task, you're going to have more pain the more load is upon it. So jumping tasks will be Sora, and then single leg tasks will also be Sora. So that's something for me is a key differential for the Achilles as far as what the person's telling you. They should get more pain and more dysfunction the more they do that is loading the Achilles. The other key differential that I have is that they've got to have some form of pattern of pain that also responds to what we would call a tendon. So we know with tendinopathy they tend to warm up. So as you do exercise, they tend to feel better. That might change if they've had it for very long periods of time, but definitely they should have that in the history. And the other thing is that they'll tend to have stiffness in the morning afterwards. So when they do, say on a Monday, a really big run or a jumping task, they should be quite stiff on that Tuesday morning. So they're sort of the keys that I'm looking for with the Achilles. You also are making sure that they don't have any weird symptoms like any pins and needles, tingling, numbness, all of the sort of things that you would do to rule out those other sort of diagnoses, assuming you've also screened the back and the knee and all the other potential referrals of things to the posterior calf and Achilles region. So they're they're really my big key differentiators. One of the things I don't rely on hugely is imaging and palpation. The reason I say that is we know that both imaging and palpation are extremely good for ruling things out. So if I've got a patient that has no tenderness on their Achilles when I palpate it and they have no changes on their imaging, I'm very confident that they haven't got Achilles tendinopathy because it's really good at excluding the diagnoses. But unfortunately, we know that for both palpation and for imaging, the amount of times that you can see ace like findings in an asymptomatic population is really high. So they're not very good at ruling in the diagnosis. So there's something I definitely use in the picture of the patient, but not something I would hang my hat in on as far as diagnosing them. I'm definitely more reliant on that symptom behavior and their sort of load provocation. And that's what I would use, irrespective of what the differential diagnosis is, whether it's posterior ankle impingement, paratinitis, any of the other issues in around the burses and the tendons, I'm only calling it Achilles tendinopathy if they've got that very clear symptom response and load behavior.

SPEAKER_02 5:30

It's sounding like for a lot of conditions, those subjective examination questions are really going to give you a lot of clues before you've even dived into the objective assessment.

SPEAKER_01 5:41

Yeah. So when I do my complex consulting for really crazy Achilles presentations, I think I would spend almost half the consult asking questions and drilling into the detail. Not all of that's diagnostic, some of it's around their training program and their loads, et cetera. But definitely by the time I'm ready to physically assess them, I'm already pretty confident that I know what I'm gonna be looking for. And then that directs what I'm gonna be doing as far as my physical assessment. And then I'm sort of just using the different tests based on whether they're good at ruling in the condition, like the load response or good at ruling it out, like a palpation, to determine whether or not I'm gonna call that Achilles tendinopathy or I'm gonna call it something else.

SPEAKER_02 6:22

And before we dive into the objective component on it, Ruth, did you have anything to add in the way of the subjective examination?

Differential diagnosis of Achilles Tendinopathy

SPEAKER_00 6:30

Yeah, no, I thought that was a very thorough response in terms of the assessment of the different things that you go through. Yeah, in terms of thinking about the differential diagnoses, I think it's kind of helpful to consider, like, you know, so if someone has pain up more in the mid-portion of the caleus tendon, you're looking to see if they may have some other sort of concurrent or, you know, some other tendinopathy that's going on. And so that's really helpful to be able to assess because a lot of times we'll be doing plantar flexor loading, heel raise or something like that. And so that's helpful to keep in mind because you get them started on their program and they're putting more weight on one side of their foot or the other. And then that could be aggravating some other tendinopathy that's going on. Similarly, thinking about if somebody has insertional achilles tendopathy and a common condition that would be with that paired with that would be planner heel pain or plannar fasciitis. And so again, like thinking about what exercises you might need to do in order to make doing the exercise program more comfortable for them and potentially making some modifications to like toe positioning and stuff like that to maybe even progress it better to get a stretch on the plantar fascia so you can be treating two things at once. So that's kind of my other piece to add in.

SPEAKER_01 7:51

No, I I think that's great because I think this speaks to the fact that a lot of the time people want like a recipe for their rehabilitation. They want to just know what is the program that I can give to every Achilles. And what you just said completely speaks to the fact that that's never possible because if someone's got Achilles tendinopathy, but then they've also got, let's say, anterior ankle impingement, you can't necessarily train them into some of the ranges that the the recipe programs use. So it's really important in that subjective to get a really good holistic picture around all of the different sort of comorbidities, both musculoskeletal and health-wise, to determine how you'll then program. The other thing is I think it also can, if you get a really good subjective and find out what their other problems are and other musculoskeletal complaints, it sometimes explains why you'll find weird things on the objective. So it's really good to know, like if they do have the planofascia comorbidity, you might be getting them to do an Achilles test and they're saying, oh yeah, that's sore, but then actually the pain's in their plano fascia, it's not in the Achilles, so you you're completely being led in the wrong direction. So yeah, I I concur, like so important to understand that full presentation in the in the subjective.

SPEAKER_02 9:02

Then moving into the objective piece, it's sounding like you're obviously listening out for these hallmark features of Achilles tendinopathy, and sometimes you'll have subjective features that might make you be suspicious of a concurrent pathology. What sort of objective findings can help you confidently diagnose that as an Achilles tendinopathy? And what might you typically see that might result in that differential diagnosis or a concurrent diagnosis?

SPEAKER_01 9:28

So I think for me, I actually don't have a lot of diagnostic tests that I use to rule in the diagnosis. For me, most of the objective assessment that I'm doing is about ruling out other pathologies. So it could be that I'm looking at, you know, determining whether there's any crepitus throughout the Achilles, if I'm concerned that there's a if the pathologies are paratoninitis. It might be that they've got pain with passive plantflexion, which would be not something you would see in an Achilles. If someone's got pain at the end-range plantarflexion, that's not an Achilles presentation, that's posterior impingement. So they're the sort of tests that I would use to rule out the diagnosis. And the same as imaging and palpation is that I use them mainly to rule out. But other than a load progression test, and for the Achilles, I follow the progression that's in the tendinopathy severity assessment, which is our double leg calf raise, single leg calf raise, double leg jumping task, and single leg jumping task, because A, it's easy to do in clinic, you don't need any specialist equipment. But if I rate their pain when I do that assessment, I can also start recording those components in their severity assessment. So I tend to do that sort of test. So five reps of all of the tasks and go from there. I think the biggest thing when you're doing the objective assessment is just to make sure that they're doing the tasks the way you think they should be. So one of the biggest pitfalls that I see with the Achilles is clinicians will do a load assessment test and they'll do double-leg jumping and then they'll do some form of one-legged jump or hopping on the spot. And the patient might have less pain with the one leg than the two-leg, and they go, well, it can't possibly be the Achilles. They've got less pain. But when you then look at how they're doing it, when they're double-leg jumping, they're landing on the front of their foot, they're using their Achilles as a tendon a spring. And then when they go to the single leg on the affected side, they're landing totally flat-footed, they're not using the Achilles as a spring whatsoever. So you've almost been tricked into thinking that they don't have pain. But when you make them do it properly, all of a sudden it is really painful. So I think with my objective, it's more about those load progressions, taking them as far as they feel comfortable, and then making sure that they're doing the movement task correctly to get the information that I that I want. The same would be true of like a single leg or double leg calf or heel raise, is that if someone's going from complete pronation and then completely just sort of inverting, they might not actually be going through a lot of plant deflection load. They might just be using those other tendons on either side of the foot to actually get some some height. So you're not truly assessing the Achilles either. So just making sure that they've got good technique with the progressive load assessment is sort of my biggest key for the objective. Otherwise, I'm not really that fancy with my objective assessment. I'm I'm pretty plain chain with that, because I'm I've got most of my information from the subjective, and I'm sort of just making sure that there's nothing funny going on when I then do the objective.

SPEAKER_00 12:22

I'm relieved to hear that you don't have some magical objective test that I haven't heard of before. But yeah, no, I I use a similar,

Objective findings in Achilles Tendinopathy

SPEAKER_00 12:32

a similar approach. So, like one term that you could put on this progressive loading that Miles is talking about is looking at movement-evoked pain. And so with that, I like to look at pain when they're sitting at rest, no weight on their feet at all, and then look to see when you progress them into a tendon loading exercise like the heel raise, how much pain are they having with that? Like it's hard because you think of Achilles' tendopathy as generally the greater load that you put on the tendon, the more pain that they have. And so you would expect you'd go from sitting, let's say you have a one out of 10, you do heel raises, you'd have, you know, maybe a three out of 10 and then hopping and be a five. However, we so often find that people cheat when they do the hop. And so their pain will be less than the single heel raise. So I wouldn't like I think that, you know, Miles' point of looking at the technique that they're using as they're doing the single leg hop is is really critical. I wouldn't be like, oh, they don't have a load dependent pain because it's less when they hop. So I often will like when I'm looking at a at a task like single leg heel raises, I like to do look at endurance to see how many they can do. And so it's kind of nice because you're you're dual tasking because you're assessing planner flexor performance. And then at the same time, you're also getting their pain when they do that. And then you just have to make sure to ask, where are they having the pain? Is it in the Achilles tendon or are they getting fatigued at the calf and just clarifying, or are they having it at like the along the metatarsals? I often evaluate with them barefoot. So anyway, so if they aren't doing OSUs and there's some tenderness, so anyways, just making sure that you're assessing where it is that they're having pain is helpful so you aren't getting misinformation.

SPEAKER_02 14:12

Fantastic. I think that's both of you have said really useful information for clinicians. So it's it's quality, it's the endurance, it's anticipating what maladaptive patterns they might have that all fits into that clinical picture of the subjective painting that has been done thus far.

SPEAKER_01 14:28

The other thing that I really use when I'm doing that sort of load progression test is figuring out why they won't do the task. So what isn't uncommon is someone goes, I can't single leg heel raise, I can't single leg hop, I can't do it, I won't do it, I'm not gonna do it. And trying to figure out why. And I know Ruth did a lovely study on this, looking at the reasons as to why people wouldn't do some of those tasks, as far as they were worried they were gonna rupture, they were worried that they were gonna have pain. So I try and get that because for me, as a someone that's gonna provide them exercise rehab, that is a really big help for me to know if I give them a program, what do I need to change in this treatment session right now to make sure that they're gonna do my program? Because if they're not even confident to do a single leg heel raise because they think they're gonna rupture their Achilles or they think it's gonna be agonizingly painful, then I'm gonna have no chance at giving them a program. And I need to change their mindset in that consult right there on the spot. So I don't know if you want to expand on the study that you did, Ruth, but that for me is a really important one that I pick up early because it it really informs my treatment direction.

SPEAKER_00 16:01

So, yeah, so we it was a survey-based study and people that have Achilles tendopathy pain. And so in the survey, we were trying to get at, you know, like what is just these things that we've been talking about, you know, what is your pain with rest? What is your pain with heel raises? What is your pain with hops? And then we allowed people to opt out to say, like, no, I don't want to do the heel raises or no, I don't want to do the hops. And then we'd ask why. And part of that, again, they had different reasons that they wouldn't want to do it. And then we also at the team same time assessed what was their level of fear of movement. And so we used the Tampa scale kinesophobia, the 11-item version, which is a little bit shorter than the 17 item version, but I know it's still a lot of questions. But in that, we found that individuals that had elevated kinesiophobia or fear of movement, that, gosh, I'm not gonna have the exact numbers, I'm gonna misquote it, but I think it's like half, like weren't willing. Yeah, I can't remember if weren't willing to do the heel raises or the hops. But I mean, it was a surprisingly high percentage that weren't willing to engage in these exercises that we commonly prescribe. Like that is actually my my favorite moment of treating people with Achilles tendinopathy that my always talked about is like addressing that fear. And I actually just saw someone a couple of weeks ago and they were talking about because like there's so many sources of information that kind of provoke fear. And it actually kind of broke my heart because this person had come in and they're like, Oh yeah, I was talking to my PT because she had been seeing the PT for actually like a knee injury. And then she talked about how she was starting to have Achilles Tinopathy pain. And the PT was like, oh my gosh, I wonder if you're gonna rupture your tendon. Like, I feel so bad for you. Like, I'm really worried about you. And I was like, oh no, that's like the so, anyways. So then when you get to like bring them in and be like, no, it's okay. Like you're in the group that has pain, which is a very different than the group that goes on to rupture, which usually most of those never had pain to begin with. And that is just like a huge relief for them. And then they feel, you know, safe and able to engage in exercise. And it's it's wonderful. I feel like that's like the best part of PT.

SPEAKER_01 18:15

It's good. Like there was this really cool study that was published recently where they did like a deception model for people with Achilles, and they had people, they got them to hop and record what their pain was, and then they put them through sort of like an educational intervention. And there was different interventions, but one was basically like the standard bioanatomical description of this is the Achilles, this is the structure, this is what's happening when you're loading. And the other was very much like a pain education, like this happens, it's fine, nothing to worry about. You get this warm-up, it's protective, it's all the things. And they're able to show that that immediate education session, when they retested people's hops, had a massive difference in their in their pain. So they were able to actually massively reduce people's pain within a very small session of that load task just by actually providing really positive enforcement, which speaks to everything that Ruth just said with the fear as well. So that's something from the assessment, even though you might be in your head going, I'm assessing, I'm trying to figure out the diagnosis, you'd need to be so cautious from the beginning about the words and the language you're using, but also trying to figure out whether there's any of those psychologically ingrained things in the person that are going to be barriers to then your treatment, because you want to start breaking them down as early as possible.

SPEAKER_02 19:32

Fantastic point. So I'm curious for the clinician listening, what's your elevator pitch for the patient that comes in and says, I'm too scared to move? What does your pain education sound like? And how do you link it to the evidence around rupture or non-ruptures?

SPEAKER_00 19:47

So, you know, in terms of thinking about exercise and education, a lot

Pain education in AT

SPEAKER_00 19:52

of times people really focus on the exercise piece. And don't get me wrong, I 100% agree that's very important. But I think that the education is actually equally important because it allows people to better engage in the exercise. And so some of the key pieces that we include in our general education would be going over just the terminology of understanding, because people use so many different terms in terms of tendinopathy, tendinitis, rupture, and making sure that they know that their diagnosis is different than someone who's rupturing. What are the common symptoms, the expected recovery timeline? So if they aren't expecting, like, oh, I'm gonna be here for two weeks, my pain's completely gonna go away. And it's like, no, we we actually need to teach you strategies that you're gonna have to use, you know, for six months, a year, rest of your life, keeping your tendon health up and being able to manage flare-ups over time. Importance of doing some sort of exercise over rest. So if they have a flare-up, they don't just sit on the couch, but continue to do some loading onto the tendon in a way that's not super painful. And then giving make sure they have strategies to be able to lower their pain and to find pain relief. And so, for example, I usually, so in in the exercise studies that we've done, I have to give credit to Ebony Rio is the one who like designed our exercise strategy. So I pulled that over. And so we always I always like to start with isometrics for the first week and mainly just because I think it's a really good tool. So even if they have a really bad flare-up in their tendon pain, they can still be loading the tendon in a way that's static, low pain, low fear, it's a really approachable way. So you have those strategies in there. And then in terms of thinking about the pain science education, I would say the typical pain neuroscience education that often has this component to it that's really focused on central sensitization or nocyplastic pain, depending on what term you want to use for that. When you think about you have changes in the central nervous system where you either have increased facilitation or decreased inhibition so that the intensity of the pain is increased. So a lot of times what they will tell people is to not pay so much attention to the pain. And it's kind of like a fire alarm that's going off, but everything's okay. And so, you know, and so not, but it's almost like the reverse for Achilles tendopathy because we're actually kind of why to some extent, the pain is actually super helpful and important for them to guide. rehabilitation. So as Miles was bringing up earlier, you know, we really emphasize trying to figure out like how does your tendon respond the next day? Do you have more pain and stiffness the next day, or is it less or is it about stable? And then that in helps inform them whether or not they can increase the load on their tendon or decrease it. And so I think that pain is a very good and helpful thing that we can use use in Achilles tendon rehab. And so I think a lot of it, a lot of education is really just focused on how do you interpret pain and how do you use it to make sure that you don't get you get that boom bust cycle where your pain flares up, you do nothing and then you go and they start back from zero and and slowly progress up. Miles, I'm sure you have some thoughts as well.

SPEAKER_01 23:14

Well not really that was great. Like I would do the exact same thing. I think for me the key is I don't provide the traditional pain education similar to what Ruth said as far as I guess central sensitization and all of the things because Achilles tendopathy is a little bit different. It does still tend to have that really load dependent response which we don't always see in conditions that are centrally sensitized. The literature's a bit mixed as to how important those central sensitizers are in the in the Achilles realm. But for me it's going that the pain that I'm most interested in is your next day symptoms. So what are you like? How do you recover? Because Achilles tendinopathy warms up, someone might start their jog at a nine out of 10, but then be zero out of 10 and fully warmed up within 10 minutes and pull up the next day without any pain. That's probably okay. I'm far more worried about the person that has a two out of 10 pain when they start their jog and it might warm up a little bit but then the next day it massively flares up because the person that has the massive flare up is the one that to me is having the indications that their system's not tolerating the current loading. So I use that sort of education around the symptom monitoring and being aware of it without being paranoid. Like you know if it's a two one day and the next day it's a three, that could just be the fact that you're not very good at telling the difference between a two and a three. Like it might not be you know the end of the world. But you know if you're going from a two to a seven or or something like that, I'm I'm definitely more concerned about that and we need to look at what's contributed to that that heightened state of pain and stiffness following. The other thing that's really interesting is we did a a study where we looked at what mattered sort of to people as far as what predicted resolution of symptoms. So we took a cohort of people that had no reported Achilles tendinopathy anymore. So they'd had Achilles tendinopathy but they said they were fully recovered. And then there was a group of people with active tendinopathy symptoms and we gave them the tendinopathy severity assessment which has different domains for pain and stiffness or symptoms. And what was really interesting is when you forced people that said they had recovered to do the load tests like the jumping and the hopping and the calf raises, they actually still tended to have pain with those tasks. But what was the most clear thing that actually differentiated the two groups was the stiffness. The group that had recovered or felt they had recovered didn't have morning stiffness. They didn't have stiffness when they got out of a chair. So it's one of those things that from a questioning point of view now, it's not something I used to ask about anywhere near as much. But since that study, I always ask the patients around their stiffness because for me the research we did demonstrates that that is something that is really important that patients perceive as getting better, which I sort of get like Achilles is load dependent. So if you avoid the things that make it sore, you can probably not get load pain, right? Like if you don't hop and your pain is with hopping, you won't have hop pain. So it's easy for them to score zero or to massively improve that. But until their stiffness and those sort of things get better, that probably to them indicates that they aren't they aren't recovered. So that's something I will also include in the education piece.

SPEAKER_02 26:17

Yeah fantastic which I think is a really good segue into reactive versus longstanding presentations. And Ruth I might throw to you for this one how does your management differ between a highly irritable or reactive presentation and a longstanding degenerative

Reactive vs long-standing presentations

SPEAKER_02 26:33

tendinopathy?

SPEAKER_00 26:34

Typically in terms of again like going through this process of assessing what is their level of pain with loading, you're trying to get a sense of is the typical home exercise program progression that you go through, is it going to be a good fit for them or not? So I think of kind of the typical chronic Achilles tendopathy is generally a pretty good fit for you know a progressive Achilles tendon loading program. If you get somebody who isn't able to do a single leg heel raise at all, or they're able to do two and they're at a nine, you know, then you're like, okay, I think we got to start at a different approach. So typically for the progression you're trying to get as high a load as tolerable. Whereas for this group if they're super irritable, I'm just going for getting some muscle activation going to prep them for the next stage when we get to loading, but it might even just be seated calf raises or double leg isometrics and planner flexion, just something that's super low level that they can do with a very low level of pain. And it gives them some confidence in being able to do exercise without pain. I was actually at a conference I loved and they're talking about how one of the purposes of the exercise is actually learn to be able to move that you can do movement without pain. And so that's probably one of the key things that I'm just trying to get at in terms of what are what are ways that they can start to move it. And then also that would also be where I think I would start a lot with education, which is easy to do. I guess I usually almost give everybody heel lifts I know the evidence for that is mixed, but you know it's cheap. It has low adverse events in terms of like cost and time. And so like I'm trying to just give them strategies, you know, try this, put these in your shoes, let me know if it helps over the next week. And then you might I might even consider also doing something like manual therapy or dry needling or just something to keep them engaged, give them some pain relief and try to get them back to next end and hopefully eventually we can get them onto progressing into loading.

SPEAKER_02 28:45

Fantastic. That all makes sense a really nice mix to get them on board and help with that symptom calming strategy. Miles, anything to add there?

SPEAKER_01 28:55

I wouldn't add a lot the only thing is I don't think of tendinopathy in the realm of reactive and degenerate. Like I know that the the work by Jill Cook and Craig Purdom, the pathophysiology and the continuum of tendinopathy that they've developed is so helpful as far as understanding the underlying changes and the rationale for the changes in the tendon. But clinically I I don't always know if it's helpful because if you look at the way that the continuum is structured, we know that a lot of the things in the continuum occur irrespective of pain. The association to pain isn't always there. So I probably think of tendopathy similarly to the way the I guess the osteoarthritis literature will report things where they'll go that they've got their sort of background symptoms and then they'll have flare ups. So I I probably talk more about when they get a flare up as opposed to when there's a reactive tendon and stuff like that. Because again reactive and maybe it's just me but it sounds very alarming whereas if I say oh you've had a flare up people know oh flare ups don't last forever they're they're just transient. They they flare and then they they calm. Whereas reactive tendon and stuff like that, you've then got to describe all the bloom and pathophysiology which I know most patients aren't super keen on. But yeah so I I probably tend to use the words flare up of and background symptoms or or normal symptoms and things like that as opposed to reactive and degenerate. Obviously from an imaging point of view reactive and degenerate is a little bit of a different conversation but but clinically I'll tend to talk more about flare-ups than the the continuum of tendinopathy.

SPEAKER_00 30:55

Yeah just to add into that so for the Achilles tendopathy clinical practice guidelines from the American Physical Therapy Association, yeah we termed it high symptom irritability versus low symptom irritability, which I think gets gets it kind of these same concepts that you guys are getting at. But yeah, I think it's it is important to distinguish between the two because you don't want to just take, okay, here's a progressive Achilles 10 loading program. We need high load we do it for everybody. There is some some distinguishing where like there might be a group where you have to start with a different approach for a little bit to help reduce the pain before you can push them on to that high loading program.

SPEAKER_01 31:33

Yeah. And they're often different presentations. So you'll see more of a persistent tendinopathy probably in a sporting setting when you're working with a team because that persistent low grade symptoms tend to be things that more aggravate performance. So someone that's got that low grade tendinopathy in the Achilles that is manageable but they're just feeling like they're unable to push as hard as they want to push because of the tendinopathy. Whereas in clinical practice you tend to see people during a flare up when they're really symptomatic and they're coming in and they're seeking treatment because they're they're not coping or they've had that big flare. And that's where I think this to me if I've got someone in a flare up my target is really around load modification, education and then simple exercises. Like the people can debate about isometrics as much as they they want but for me with isometrics they might have pain relieving effects they might not the easiest thing to do is just try it and see if it helps the person. But then the the second part of that that I love about isometrics is people just think they're safer. So if you tell them just to hold that position and you've got that really fear avoidant person and you go, nothing's going to happen, you're really safe like people don't rupture their Achilles when they're just holding on you build that confidence and you get them to engage with the loading even if they're in a flare up because even if someone's in a huge flare up or they've got a hugely reactive tendon, whatever you want to call it, there's usually a position that you can find in a plan of flexion movement that they can undergo really high loads and be pain free that just allows you to get that that buy-in.

SPEAKER_02 33:04

Fantastic that all makes sense I think that's a nice segue into loading programs and progressions. So I'm curious what does your current gold standard load program look like? And how do you decide when to progress from strength to energy storage to plyometric work?

SPEAKER_00 33:21

My typical progression is yeah I like to start everybody with

Loading programs in AT

SPEAKER_00 33:25

isometric for a short period of time. It's like one week do the isometrics and you know a lot of times it's actually surprisingly hard for even like athletic people to be able to hold and do an isometric. Like it actually can really work their calf muscles because they haven't practiced it. So anyway so it still can be like physically challenging for even uh higher level people and then as quickly progress them into doing single leg heel raises. And then I think of that as like so I I kind of usually so again I have to credit Ebony for this so like kind of three phases. So we have static load with isometrics and then you have a slow controlled load with heel raises. And then the third phase would be you know a more quick dynamic or spring phase where you're doing those quick push-off and in each of those phases you're trying to gradually increase the amount of loading that you have on the tendon. And so in terms of thinking about you know people going through like I generally don't have like the the majority of the people that come through for us are not high level athletes. And actually a lot of and so like a lot of them if they're just getting back to a walking program, we don't need to take them into like single leg hops like they're gonna be fine without doing that. And so sometimes actually we'll just go through the single leg heel raises and then instead of doing those, you know, typical what you think of for plyometrics, we just transition quickly into just their walking program and making sure that they are increasing their distance and talking through with them in terms of you know having their big walking day and then a resting day and then a big walking day and then a resting day and how they mix that in with the single leg heel raises long term so that they're still doing some of their like level of spring phase as their activity that they like but still maintaining exercises to maintain the tendon health.

SPEAKER_02 35:22

That sounds like a very patient-centered approach. Miles, your thoughts?

SPEAKER_01 35:26

Yeah so I think the first thing you've got to do is figure out what the person's doing in their week. So if I'm if I'm reviewing a complex Achilles but they're still training and they're a field-based athlete, whether it's football, whether it's court-based sports like basketball, if they're still training and they're still playing, there's no way I'm prescribing them any energy storage and release because they've already got that in their training. And that's probably one of the biggest faults that I see is people try and work on people's hop performance or something like that while people are still actively training. And what that does is it just eats into what that capacity is of that tendon or what it can tolerate. So you might be prescribing some energy storage and release rehab but in order to do that you've got to pull out of their training which is never going to be something that's going to get you on side with the coach and it's probably not going to get you on side a lot with the with the athletes. So I'll always look at in the week what are the things that they are doing and what can they tolerate? And that will inform how much sort of energy storage and release they've got naturally through their own program and then I'll decide whether or not if they've got nothing then I might need to prescribe them something. Then my program as far as my gym based rehab is a little bit sort of on a continuum in the way that they'll always have an isometric. They'll always have some form of isotonic that they'll have this thing the whole way through. So what they might have initially is a really long hold isometric. So that they're doing long hold isometrics, 45 seconds, they're getting confidence with the movement, they might be getting an analgesic effect with the movement, but it's working very much on an endurance basis. And then as they over time I'm going to reduce the duration of that isometric so that by the time they're actually getting really good, they might be doing two or three second isometric holds that are extremely heavy and they might be doing upwards of 20 to 30 reps in a session. So that they they'll keep isometrics in the whole time. Then with my isotonics initially if it's say an insertional Achilles we know that they've got a lot of problems in dorsiflexion. They might be doing pulses. So they might be doing you know five to 10 degree movements at the top of their range where it's completely pain free that they can do there's no pain whatsoever irrespective of how painful or how much of a flare up they are in because they're so far outside of their provocative movement. But I can do that. I can give them you know 30 to 45 seconds of pulses and they're going to feel the burn really hard in their Achilles. I've had elite level basketballers come in that have got this horrific Achilles pain and they can't even do 30 seconds of pulses at the top of a planar flexion range because they're they're so deconditioned. So that might be how I start that and then over time they start working through more range of motion and they might start going heavier and I might transition them into standing and sitting and weighted and unweighted but they would be doing some form of isotonic so that concentric and eccentric component the whole way along and I will just continually make that heavier as I go. And the way I tend to structure my rehab is I tend to have sort of different days A, because it helps me fit it in, but B, athletes get really bored. Tenant rehab does take a long time. So if you're giving them the same thing all the time they get a bit dull. So I might have a day where they're doing their endurance work because things like their endurance calf raise so you know as many bodyweight reps of their heel raise to failure, that's an endurance task and it might not be as good as doing it fresh, but that's something they could do after training. They might not get as many reps as when they're fresh but the fact that they're doing it under fatigue after training means that they're still going to be really well working the endurance. So that's a exercise that I can give that doesn't add a lot of time. Then on other days when they've got more freedom that's when I'll prescribe the gym based rehab when they're doing either that sort of heavy slow resistance type regime or those sorts of exercises in a in a gym. And then they might have then the isometric program that they might do as something which is a warm-up initially to training. But then on the days where I'm going heavy they might actually have 20 minutes of dedicated heavy you know 30 to 40 reps of two to three second extremely heavy isometrics where we're working mainly on that tendon stiffness element. So I would mix my program up a little bit depending on the the group but that's mainly in an athletic setting in the sedentary population I would do something similar but as Ruth said I don't have to get them to being able to do the Olympic triple jump. I just need them to be able to to walk or do their activities of daily living. So the capacity that that person needs is is very different. So I don't think that there's a gold standard. I think there's a gold standard for each person that you see because what will be good for one person is not going to be good for someone else. We know that even based on the sport basketball players have so many ankle injuries generally they've got a lot of anterior ankle impingement. So if you wanted to train them into a lot of dorsiflexion with your Achilles work you're gonna find it really hard because they'll get anterior ankle symptoms and then you'll be having problems whereas other sports don't have as much anterior block and you can go through different ranges. So you've got to consider all of these different types of factors I think when you prescribe which is why there's never going to be the the perfect program that will work for everyone it needs to be individualized for the person or the athlete that's in front of you.

SPEAKER_02 40:37

For sure. And just a a question going back to something you said you mentioned heavy slow resistance for the clinician listening how is heavy defined by you relative to the patient?

SPEAKER_01 40:48

Yeah so heavy gets thrown around a lot. So the Alfredson's eccentric protocol which was based off the Kerwin and Stanish protocol was called the heavy eccentric

Heavy loading programs

SPEAKER_01 40:58

protocol but it was actually 180 reps of eccentrics every day, seven days a week for lots of weeks that by definition of what we would say in a strength and conditioning realm now is not heavy. If you can do that many reps it heavy is not the word. So that isn't what I would call heavy I would call that more of an endurance type task. In the study that was done by Bayer where they used heavy slow resistance and compared to the ecentric protocol, they did a progressive thing so they started, I think it was with sets of 15 reps and they transitioned all the way down to sets of six. So they went pretty heavy but that program was double leg. So again I would challenge how heavy that is potentially for the affected side because we know people with injuries irrespective of whether it's a tendon or something else they're very good at cheating. So as soon as you go double leg, I think there's that capacity that they don't work that affected side anywhere near as much as they should. And we know that there's usually asymmetry in strength between sides which makes it harder. So I would always train single leg. So that would be my first tip to make it heavy is go single leg. And then from a rep range I very much base it on their training history. If this is someone that's never ever set foot in a gym and never trained, I will probably start at 12 to 15 sort of rep max type range and do a few sets of that. But then I'd like to transition them down into somewhere between a six to eight rep range where it is really heavy. If it's someone that's well trained I might start them on six rep max to begin with. But the key with these is I'm making them slow. So that's the heavy component the slow component is that you're wanting at least five seconds of time under tension per rep. So that might be a two second concentric, one second isometric and two second eccentric or one second concentric, four second eccentric, break it up however you want, but it needs to be slow. And the reason it needs to be slow is we know that tendon tissue is not aggravated by heavy loads it's aggravated by fast loads. So that's why people will get problems with more problems with hopping than a single leg calf raiser even though if you look at the amount of load over time the calf race is much slower. So you would want to go slow because then you're making sure that the person's not going to get any symptoms and part of the the way to do that is again to watch the the form as an as an example now I think a lot of people test calf raises and count how many calf raises people do and they do them to a metronome. Okay great idea fantastic it really helps but when I look at how people assess that often what happens is that they use the metronome as the start point. So it might be every second they go up on the second down on the second or whatever it might be but they go up they the metronome goes and then they go really quick and then they sort of hang at the top until the metronome beats again and then they go down. You need to sort of avoid that jarring or that bouncing type movement. And you want to if you're using a metronome or using something else to pace to make it slow, you want to take the entirety of that time to do that task as opposed to do it really quickly and then have rest time naturally built in so that it is truly slow. And that's what I would call heavy slow training.

SPEAKER_02 44:04

Fantastic thank you that's really helpful. Let's cruise into talking about insertional versus mid portion presentations. How does your assessment and exercise prescription differ from those two presentations Ruth I might throw to you.

SPEAKER_00 44:20

So people who have insertional Achilles tenopathy I guess in a way kind of have like a bad reputation

Insertional vs mid-portion presentations

SPEAKER_00 44:26

in that people think that they don't do as well with rehab as people who have mid portion Achilles teninopathy and and so we did a clinical trial we were looking at the effects of different types of education but within this we recruited individuals with insertional Achilles teninopathy and mid portion and actually both groups improved by the same amount. Part of the reason for that is that we did make one key modification which was typically When people think about doing single leg heel raises or loading for the tendon, they're going into end range ankle dorsiflexion, which for people with insertional Achilles tendinopathy, that compression against the tendon, peritone, fat pad, all those insertional tissues, we don't actually know where the pain is coming from, but something in there is getting compressed and it's contributing to pain. And so the exercise can be aggravating your symptoms. And so we actually just did to neutral for both insertional and mid-portion. And actually everyone did just fine. And again, it depends more like on what your goals are. If you're working with a sprinter who needs to get into, you know, dorsiflexion range or, you know, then it makes sense. Obviously, you'd want to go into the range of motion that they need to be using for their sport, but it's not necessary. The other thing I would say is that even in people with mid-portion Achilles tenopathy, at the beginning we were kind of talking about other differential diagnoses. So plantaris involvement may be a contributing factor to people with mid-portion Achilles tenopathy who also have pain when you go into end-range ankle dorsiflexion. And so regardless of whether they have instructional or mid-portion, I just like to have them do a calf stretch and ask if they're feeling a stretch or if they're feeling pain. Like, does this reproduce your pain? If they're having a reproduction of pain, then I give them a heel lift and I just do all the exercises to neutral. And then once they can do that, then later on we can progress into end-range dorsiflexion if they need it for their performance. But I would say that's really the only difference is taking that into account.

SPEAKER_02 46:32

That's really useful. So it's sounding like it's very much individualized, less so about defining as a mid-portion or insertional, but rather basing it off the symptoms. Great. Miles, anything to add there?

SPEAKER_01 46:45

Only that there was a a recent clinical trial that was done in relation to this. And it was a beautiful trial that basically just took all the compression elements out. So it got rid of the dorsiflexion elements of all of the training and tried to get them out of that range as much as possible. And it was, it was led by Lauren Pringles. And what they showed was that if you actually remove the compressive element, the group will do so much better than if you actually leave that that in. So I think that the insertions trying to amend the rehab so that they aren't going into that dorsiflexion range is massive. And I think clinically you can actually get better improvements in the insertional group if you do a really good job of changing the program as opposed to, yeah, like Ruth said, they've got a bit of a bad rep for not doing well. But that's because the program was designed for mid-portion. The other thing that I think is more important for the mid-portion, uh, sorry, for the insertion, is you need to go through their entire week and look at what they're doing in the week. Because in the insertions, if they're an athlete and they're doing tons of deadlifts and they're doing tons of squats and all these things in the gym and they're getting into huge amounts of ankle dorsiflexion in deep squats and other things, you might want to just recommend that they put their heels on plates or wear lifting shoes and stuff like that so that they can still do all their S and C. That's fine. But you're just changing it in a way that it's going to be less aggravating from the for the tendon. And then if you're aggravating it less in the gym, that means they've got more capacity to train. And that's so I think that's a real big one for me is looking across their program and not making the dorsiflexion the enemy, but just going, okay, if we if we take some of the dorsiflexion out of here, we can add you to let you train more or you have less pain so you can train more. And that might not be the long-term strategy. Once they're through their flare-up, whatever it might be, you might reintroduce it. But for me, it's all about in sport trying to maximize the amount of time that they can train and do their athletic activity. And if we can tweak things to where we still get the same neuromuscular gains that we wanted in the gym or whatever else, that's our responsibility as the clinician to look across the program and and change that for them.

SPEAKER_00 48:54

Yeah, just to add into that, I think the other thing that I that I like is that a lot of times people will, they won't know exactly what are the factors that led to a flare-up or an aggravation of their symptoms. I had this, had this woman who was, she was like, I swear, whenever I put on heels, my heel pain decreases. My husband thinks I'm crazy. And I was like, no, it makes sense, you know? And so because she hadn't surfed no Achilles tendinopathy. And so I think like explaining that, and then people can better understand. And maybe they make the choice of, you know what, I'm gonna really push. This is like the key time when I've got to get out of my garden. I'm gonna do it. And I know I'm gonna have a flare-up, you know, but it's like it's a known thing. And they're like, okay, and now I'm gonna recover. And it's a choice rather than being like, oh my gosh, like why did this happen? And so again, I think it comes back to the the education, the education piece of like treatment.

SPEAKER_02 49:45

It's sounding both of you have made a very, very strong case for how important the subjective exam is and that education piece is and really understanding what it is you're assessing and what and why it is you're treating what you're treating. So I'm curious, just as a wrap-up question on the topic of key clinical takeaways for clinicians, what's one thing we should start doing and one thing we should stop doing?

SPEAKER_01 50:10

Okay, I think the the key takeaway from me when you're managing

Key clinical take-aways

SPEAKER_01 50:15

attendant is you need to look across their entire week and figure out exactly what they're doing and what their goals are. Because as physios, I think traditionally we've been really good at telling people to stop doing things, stop running, stop jumping, stop doing whatever. Whereas if we're smart, we might be able to change the way they load in different tasks, like I just mentioned with changing the gym or other things, that actually means that they can still keep doing the sport or the activity that they really love, even if it's walking. You know, in the patient that Ruth just mentioned, you know, if she loves walking, put her in some big, you know, wedges and get her to, you know, walk around in huge wedges. And then all of a sudden, just from an education and a load management point of view, you've had a massive impact on that person's life, more than you would have with an exercise program, because we know the exercise programs take a while. So for me, it's very much looking across the entire week and trying to create a bit of a lifestyle change beyond just providing an exercise program for these people. And then the one thing that I think we need to stop doing is I think we need to stop telling people to stop doing the things they love if there's ways we can get around it. I I get so frustrated when I see a runner that's been told to stop running because they've got Achilles problems when they only probably needed to drop one running day or decrease their K's and they could have kept running. And instead, by the time they've come to me, they're so deconditioned because they've had no physical activity and they want to run their marathon that it's really hard to get them back. So I think the thing we need to stop doing is these absolutes. You must not do this, you cannot do this, you're not allowed to do this. And instead, working with them to try and figure out if there's a happy medium as far as let's let's drop it back a little bit and see if that's enough to settle your symptoms as opposed to just banning things entirely.

SPEAKER_02 52:02

Great advice. Ruth, your thoughts.

SPEAKER_00 52:05

Yeah, I'll just just in terms of re-edging it, I think the key point that we that Miles and I have both talked about is looking at pain with movement. And so making sure to add in like what is your pain at rest, what is your pain with activity, and then you can choose some activities that are meaningful to the patient that you're seeing. I think that's helpful not only for diagnosis, but also in terms of figuring out what you want to include in their home exercise program and also just tracking over time to see if they are getting better, worse, or the same. That's much more helpful than just doing like palpation on the Achilles and being like, ah, does it still hurt when I press here? Like it doesn't, it doesn't give you as much value for doing that sort of a test. And then one thing to stop would be if people have pain, don't tell them they're gonna rupture. Like that is so common. And so, anyways, that's like the one thing where I just want to do like some, I know I want to do like a television ad or something just to get the message out there because it, anyways, I feel like it's so common and it creates so much fear for people. So that's that's my one plea noted.

SPEAKER_02 53:18

I think that's fantastic advice and really useful advice from both of you. And I think listening to both of you today for clinicians, perhaps the biggest takeaway is it's really about developing that tendance capacity to meet the demands that matter to that individual, is certainly what's shone through listening to both of you today as well. So thank you both for joining us. I'm sure we are all going to very much benefit in the clinic room tomorrow from all of the clinical gems that have come out today.

SPEAKER_01 53:49

No worries. Thank you so much. Hopefully everyone got something from this.

SPEAKER_02 53:53

Thank you. Thanks, Ruth. Thanks, Miles.