Why Tendon Pain Keeps Coming Back with Dr Lorenzo Masci

Tendon pain is one of the most common issues seen in both sport and everyday life, yet tendinopathy remains widely misunderstood.

In this episode, we sit down with Dr Lorenzo Masci, Consultant in Sport and Exercise Medicine, to explore how tendon injuries develop, why some cases become chronic, and what actually drives successful recovery.

With extensive experience managing complex tendon conditions in both elite athletes and the general population, Dr Masci shares a practical and evidence-based perspective on conditions such as Achilles tendinopathy, patellar tendinopathy, and proximal hamstring injuries.

We break down what tendinopathy really is, how tendon injuries differ from muscle injuries, and why recovery often requires a very different approach than most people expect.

A key focus of the conversation is the role of imaging and investigations. Dr Masci explains why scans don’t always correlate with pain, the common mistakes clinicians and patients make when interpreting imaging findings, and why clinical presentation should often guide treatment more than structural changes alone.

We also explore the foundations of tendon rehabilitation, including load management, building tendon capacity, and how to progress safely from pain back to performance. The discussion covers why many people either underload or overload tendons during rehab, and how finding the right balance is critical for long-term recovery.

Beyond rehabilitation, we discuss where treatments such as shockwave therapy, PRP, and injection-based interventions fit into tendon management, what the evidence actually shows, and when these treatments may or may not be appropriate.

Finally, Dr Masci explores the growing understanding that tendon health is influenced by far more than mechanics alone. We discuss the links between metabolism, hormones, inflammation, lifestyle, and tendon pathology, and why clinicians increasingly need to think beyond the tendon itself when managing recurrent or persistent injuries.

🎙️ In This Episode, We Cover

• What tendinopathy actually is
• Why tendon injuries differ from muscle injuries
• The role of scans and imaging in tendon pain
• Why imaging findings don’t always match symptoms
• Common mistakes when interpreting scans
• How to “get someone out of trouble” with a painful tendon
• Load management and tendon rehabilitation principles
• Building tendon capacity safely
• How to progress from pain back to performance
• Shockwave therapy and what the evidence says
• PRP and injection-based treatments
• Why some tendon problems become chronic
• The role of the nervous system in chronic tendon pain
• Metabolic health and its relationship with tendinopathy
• Hormones, menopause, and tendon health
• Lifestyle, inflammation, and recovery
• Tendon stiffness, elasticity, and injury prevention
• The biggest mistakes people make during rehab

🎯 Who This Episode Is For

• Anyone dealing with ongoing tendon pain or injury
• Runners and athletes managing Achilles, patellar, or hamstring issues
• People struggling with recurrent or chronic tendinopathy
• Clinicians and therapists interested in tendon rehabilitation
• Anyone looking to better understand tendon health and recovery

🎙️ Powered by Mayfair Health

At Mayfair Health, we specialise in recovery, performance, and proactive wellness. If you’re managing ongoing pain, rehabilitating from injury, or looking to optimise your long-term health and movement, our multidisciplinary team is here to help.

🔗 Website: https://www.mayfairhealth.co.uk
📩 Contact: info@mayfairhealth.co.uk
📞 Phone: 020 3985 1500
📱 Instagram: @mayfairhealth

Transcript

SPEAKER_02 0:01

Welcome to another episode of Move Well, Live Well, Perform Well. I am super excited today to chat all things tendons. Tendonopathy. What is a tendonopathy? We're going to dive into all the different factors that treat on how to treat tendons and that impact tendon and how we load them. Or are we over-treating them some of the time in terms of interventions? So I'm super excited to have our guests who have known for a long time, Dr. Lorenzo Mashi here today. Perhaps I haven't said his surname appropriately. Good try on that one. He's uh Dr. Lorenzo Maschi is a consultant in sport and exercise medicine based in London. He has a specialist focus in tendon pathology and musculoskeletal injury. He works extensively with both elite athletes and the general population managing complex and often chronic tendon conditions such as archile tendinopathy, patellotendopathy, and proximal hamstring injuries. Lorenzo is particularly known for his expertise in diagnostic imaging and clinical decision making, helping bridge the gap between what we see on scans and how patients actually present. His approach combines detailed assessment with evidence-based treatment strategies, ranging from load management and rehab through to interventions such as shockwave therapy, PRP, and other injection-based treatments. His work focuses on understanding tender pathology not just structurally, but functionally, helping patients move out of pain, restore capacity, and return to performance safely and effectively. That's quite a bio. Nice. That demonstrates a bit of knowledge. Thank you. Welcome. Thanks for having me. No problems. Um nice to nice to have you here today. So let's start with uh the basics. What is tendinopathy and how do we think about this?

SPEAKER_01 1:56

I mean tendinopathy, the name tendinopathy is really just a name given to a disease process of the tendon. Yep. And I think uh we need to not overcomplicate it because we've got all these terms that we're now using, and patients often get confused as to what it means. Is it tendinitis, tendinosis, tendon tendinopathy, um tendon tears? It's it's all these names that are given for for tendon disease. So I I like to think of it as a disease process of the tendon where the tendon isn't working well and causing pain. Okay. So trying to keep it really simple.

SPEAKER_02 2:36

Cool.

SPEAKER_01 2:37

Um and I think you know, if we overcomplicate it, I think uh that can that's where confusion can set in.

SPEAKER_02 2:45

Because there was a time where we were calling it as a tendonitis previously, but but we've sort of moved away from that.

SPEAKER_01 2:54

So we tendinitis implies acute inflammation. So you know, you fall over, you cut yourself, you get bleeding, yeah, and you get bruising, you get inflammation developing, redness developing. That's not what we see in in tendon disease or tendinopathy. Yeah. Um it's a lot more complicated than that. Yeah. Uh and certainly we've moved away from calling it a tendonitis. And so what tendonitis implies is that anti-inflammatory treatments will work well with that condition. But we know that in tendinopathy, anti-inflammatory treatments play a bit of a role, but they don't play the major role. Yeah. And I think that's the the the clear distinction. Yep.

SPEAKER_02 3:41

Okay, cool. So we've both treated a lot of tendons over the years. Um probably showing in my lack of hair. Um but they're still considered pretty widely understood, and we we still don't understand how to manage them all in clinical practice, do we?

SPEAKER_01 4:04

I mean, I always say to people, uh, the more you know, the more you realize we don't know about tendon and tendon disease. Yep. And I think we've still got, even though in the last, certainly in the last 20 or 30 years, since I've been practicing in medicine the last 20 uh sports medicine the last 20 years, we've made you know big inroads into understanding the disease process. There's still lots of areas that are unknown, and by no means do we have an answer for all people, all patients with tendon disease or tendon pathology. Um that's the challenge. Yeah. And sometimes I wonder why I am seeing people with tendons because they can be really difficult to treat. And you know, I myself have uh tendon disease, you know, I've got a hamstring tendinopathy, and it's you know, literally and metaphorically a pain in the ass. Yeah, proximal hamstring. Proximal hamstring tendon.

SPEAKER_02 5:00

Yeah.

SPEAKER_01 5:00

Uh you know, how'd it come about? I just I just ran too much. Uh you know, middle-aged male male who wants to keep active. And during COVID, like most of us, increased I increased my running activity. And you know, one day I woke up and I had pain in my butt. Uh and that's you know, that's been really difficult to you know, it's interesting uh having that patient experience. You'd probably learn and Yeah, I I I I I can I completely understand the the challenges associated with treating tendons from a patient perspective, um, uh and also from a um practitioner perspective. So they're difficult, and I think you know that's that's really the challenge. Yep. However, I think there are some really good principles that you can follow. Uh-huh. And I think those principles um, you know, get most people better. Yeah. Obviously, there's a small minority that don't get better, and then we move on to other treatments. But there are sort of principles that we use. Um every tendon's slightly different. So you've got, you know, you've got say the the bigger tendons in the in the lower leg, the Achilles tendon, patella tendon, there, what we call energy storage and release tendons, so like springs, so they move up and down. Um, you know, they're they're treated somewhat differently to hip tendons, and and then they're even treated differently to you know, elbow tendons, tennis elbow, yeah, rotator calf tendinopathy. Um, they have their own little characteristics. Little little challenges, characteristics, responses to certain treatments, maybe not responding to other treatments as well. But the principles are generally the same. Yep.

SPEAKER_02 6:56

I mean, I look at how we manage tendons, and I think we do it's a complex area, but we do try to almost overcomplicate it at the same time. I have a simple philosophy with my my team and patients. I'm like, let's calm shit down, let's build shit up.

SPEAKER_01 7:15

I think I one of the criticisms I have actually with some of the um papers coming out in the and certainly the last couple of years is I think it's starting to overcomplicate our treatment of it. And I agree, I think try and keep it simple. Yeah. Um, and if you try and overcomplicate, particularly, we might get into this a little bit about strength training and you know what what strength training is good for, you know, is it is it what we call isometrics or isotonics or these different exercises you can do, it can overcomplicate things too much. So I agree. I think you you keep it really simple. Yep. What I try to do as well is certainly when I see a patient who I think has tendon disease, I want to work out, well, obviously, you know, make the diagnosis, and I could use different tests to do that to help me. But I want to work out why. There's always a why. So why did this patient develop an Achilles tendon pain? The drivers. The driver. So really important to dig down to the drivers because it may be a combination of factors. It might not just be that they've been running too much, it might be that they have certain medical diseases that might predispose them to metabolic. Metabolic hormonal hormonal. So there's there's now a sort of a a drive to work out why, and the management is not just focused on the tendon. Yes. So we're focusing on the whole person. Yep, yeah. So a very holistic picture that you're trying to achieve. Yeah. Yeah. So for example, you know, if you're if you've got someone who's diabetic, who's got a high cholesterol, who's obese, or has put on some weight, then you know, part of the treatment is improving their diabetic control or glucose control, um, improving their diet and getting to lose weight. Yeah. And we know that has a significant uh benefit on tendon pain. Yes. Yeah. Yeah.

SPEAKER_02 9:14

And we'll touch on a little bit of that. Um so how do tendons differ from muscle when it comes to injury and recovery?

SPEAKER_01 9:23

Hmm. I mean, I think the biggest difference is the metabolism. Yeah. So tendons are really slow. Yeah. And um so once they get injured, it takes a long time.

SPEAKER_02 9:37

Uh and I think Is this due to I don't think it's solely due, but blood supply plays a role in that.

SPEAKER_01 9:45

Blood supply plays a role, but there's also also the the cells, the the the little cells within the tendons that produce the tinocytes that produce the collagen. I mean, they react to load, yeah, but they're very slow. Unlike muscle and bone, you know, if you break your bone, the bone heals in six to twelve weeks or or or or less, yeah, depending on your age. Tendons take time, and and that's the biggest challenge. Yeah. Biggest challenge for the patient and also the biggest challenge for the treating um practitioner. Yeah. Because we need to set expectations. And I always say to people, slowly, slowly wins the race with the tendon war. Yeah. Uh, you know, if you want it is almost a war of attrition sometimes with tendon. Slowly, slowly wins rate. The best way to manage tendon pain is to slowly get better over months. Yep. And not to not to intervene with a treatment that might make you better and weak, but then actually might make you worse. Or, you know, so I think I think slowly, slowly wins race with tendonopathy, and that's the biggest challenge. And I think society's changing a little bit as well. People want results. I call it the TikTok society, you know, swipe, yeah, the swipe the immediate gain. And I think it's challenging with a condition like tendon uh tendinopathy where things are slow, things are slow moving, and I think I think expectations have to be set from the beginning. Yeah, yeah.

SPEAKER_02 11:15

So what what do you use from an from a scanning perspective? You know, we have MRIs and and ultrasounds. Do you use both of those for different tendons? When when is ultrasound superior to MRI and vice versa?

SPEAKER_01 11:35

Just just prefacing that for a moment, I think it's important to understand that imaging actually plays a role, but it's not the pivotal role with with tendon disease. So we use imaging to to prove what we're thinking, what I'm thinking. Yep, yeah. So I'm thinking, um, Simon, you've got a tennis elbow clinically. I'm gonna use this ultrasound to show whether you do have that or not. Yeah, yeah. Um, most of the time it doesn't really change much because it proves what I'm thinking. Occasionally it might show something that might change my don't quite expect. Don't quite expect. Yeah. Like I scan your elbow, your tendon looks normal. Yeah. That's strange. Why would you have a normal tendon if you have tendon disease processed? Yes. So it starts to get me thinking. So I I certainly the clinical assessment is the most important part. The imaging is secondary, an important part, but but certainly secondary. Now, the question about is it ultrasound or MRI scan? It really depends on the tendon. So all of the superficial tendons like tennis elbow, Achilles tendon, patella tendon, I prefer doing ultrasound. And I can do that fascia, I can do that in my rooms. So patient comes in, I assess them, and then I scan them immediately and say, Yep, it's what I think. Or actually, this is different to what I'm expecting. We need to get further investigation. So I tend to use ultrasound as a way of confirming my clinical diagnosis at the time that I see the patient rather than getting them to have an ultrasound. But there are other tendons where you need you need maybe something a little bit more complicated, something a little bit so for example, hamstring tendon, what I've got, um MRI certainly is better. It's more the gold standard. It's more the gold standard. Other tendons like biceps tendon, probably MRI scan. Yep. Um we're looking at um you know some of the hip tendons, again, depending on how well you can visualize them on ultrasound. We'd probably use an MRI in those cases. So, you know, I think it's not not the same for every tendon.

SPEAKER_02 13:46

But ultrasound gives you another dimension of investigation in terms of looking for sort of blood flow, doesn't it, that you don't get.

SPEAKER_01 13:57

And sometimes that you know, real-time ability to see muscle contraction and activation can just add other little layers of I think it it definitely can give me it it from my perspective, and I use ultrasound uh every day in my practice. I think it just gives me a little bit of extra information that can prove what I'm thinking, or maybe I'm thinking of something else. Yeah. Uh and so it's just a way of confirming what I'm thinking, and I find it quite easy uh to use uh ultrasound, and I I tend to use it every day. Um, so so certainly so I also also get asked the question: does everyone who has a tendon pain or tendon pathology or tendinopathy, do they need an ultrasound or do they need an MRI scan? The answer is no. I think you know, if you present with what seems to be Achilles tendinopathy, but there's no other complicating features, then I think managing the tendonopathy, and we'll get on to a little bit about management, without an ultrasound is completely reasonable. Now, if things don't settle down after, you know, six, eight, ten weeks of rehab, then I think it's rehab. Appropriate rehab, which again we'll get into. Yeah. Then I think it might be time to to to investigate. To investigate. Yeah.

SPEAKER_02 15:13

Yeah. Yeah. And look, definitely, I mean, I use ultrasound as well in in our practice, and I think it's a really nice way to build confidence for the patient and validate what you're assessing. But I think for a simple Achilles, it it's relatively easy to see that someone's got a mid-portion uh, you know, probably degenerative tendinopathy, but the extent of that maybe you're missing a little layer of information, but it doesn't generally change your management, does it?

SPEAKER_01 15:46

Not not initially, as uh in in almost all cases. Yeah. I mean, there's always exceptions a rule. Yeah. You know, I can talk about exceptions, yeah. But the vast majority, 95% of patients, uh, it doesn't really change what I do um to to any major degree, except confirming that yes, they're on the right path. Yep. And it and it validates what they've been doing. Yep. Yeah, which I think is often reassurance. It's re reassurance. And as we said, it things are slow, right, to improve. So which they are with tendons. You know, they are with tendons. So you want to make you want to you want to ensure that you're on the right track. Yeah, yeah, yeah. Yeah, because if you're not on the right track uh and you need to have another treatment, uh then I think it's you know better to maybe know a bit earlier in the in that process. Yep. So I think, but on the whole, most most of the time it just validates what I think from a clinical perspective.

SPEAKER_02 16:42

Often with imaging, we see this mismatch between what we see on scans and the actual pain. Um is does that that is that still the case with tendon pathology?

SPEAKER_01 16:58

Absolutely. Yeah. Yeah. I think it's I mean, it it sort of pervades most of musculoscular medicine in general. You know, you've got someone who's got knee osteoarthritis and x-ray. Yeah, severity of the x-ray doesn't necessarily correlate with severity of knee pain. Yeah. Same sort of thing in tendon pathology. And for all the tendons, really, I mean, you know, you've got some patients that have severe tendon disease on ultrasound and no pain. Yet they're fine. They're fine. Yeah. I remember seeing a um uh elite uh iron woman who came in about um, I think it was about Achilles tendon. Uh, and so I scanned her, she had sort of major pathology, although I had to have much pain. And she said, Oh, you know, my arch hurts a little bit as well, under my arch, my heel hurts a bit, and my my elbow a little bit, and you know, she had significant pathology in these areas as well, but she wasn't feeling yeah, wasn't feeling pain. So I think that just goes to show that yeah, it's not a direct correlation, yeah, and that there are many other factors as to why people get pain. Yeah, uh quite complicated. But I think in general there may be some sort of um correlation, but not a direct correlation.

SPEAKER_02 18:16

But so in those situations anyway, we're treating the clinical presentation rather than the imaging, aren't we?

SPEAKER_01 18:22

Yeah, exactly. Yeah. The other thing with imaging that's a little bit limiting is that it's not it's great for getting a diagnosis or to confirm a diagnosis, not so good for following up patients. So as a general, I don't I don't um do repeat uh ultrasound scans um unless would wouldn't would often come in. Oh, can you scan my exactly?

SPEAKER_02 18:43

Oh, good. I want to see the progress of it. Yeah, well, no, yeah, because you're not gonna see much change. I want to know how how you're functioning, I want to know your strength marks.

SPEAKER_01 18:52

I want to know your packs. And that's the limitation of imaging, is it uh certainly the imaging that we have at the moment, maybe in the future that might change. We have some you know unique imaging modalities that are coming through. Maybe we might be using those um practically uh soon. But um, you know, estography with ultrasound. Um ultrasound tissue characterization, where we're looking a little bit more at the structure of the tendon in a bit more detail and colour coding the structure. Yeah. And maybe we could use that as loading and how it's been underloaded or overloaded, or how it's progressing with the rehab program and whether structure is improving. Um but as a as a general rule, ultrasound and MRI scan, the standard ultrasound and MRI scan that we have is not very good at uh comparison data. And what we tend to see is that patients often improve first before the imaging improves. Yep, yep, yep. Um and so I don't tend to use it so much. The only time I'd use it is if something changes. Yeah. Patient gets a lot worse or their pain changes, and I think, oh, I'll have another look and just make sure there's no no significant changes or they've not done a tear or something else has happened. So you're using it to check when when symptoms have worsened or changed. I think you could say, let's let's maybe look at doing another ultrasound, or do I could do an ultrasound in my rooms or doing an MRI scan? But as a general rule, no, I wouldn't I wouldn't keep repeating the MRI scan. Yeah, cool. That makes sense.

SPEAKER_02 20:32

So when someone has a presenters with a painful tendon, what are your first priorities? You know, is that just to try and quieten things down? Is it to reduce pain? Is it reassurance, get them into the right exercises? What's your approach?

SPEAKER_01 20:47

My approach is so I want to work out why. Yep. I think that's really important. And generally you can tease out why people have developed uh tendon pain or tendon disease. And generally, for younger people, as a general rule, it tends to be overload. Yep. Um, and so so what I would do in that case is speak to them about what they're doing, yep. And cut out those really high load activities. For example, you know, you've got a runner who, you know, has marathon coming up, um like I'm sure you've seen slenty of those over the over the last two weeks. Yes. Sure we all have. Yeah. Yeah. Uh you know, uh the run runner comes in with Achilles tendon pain, um, has been doing, and I hear this all the time, interval running sessions, and suddenly their Achilles blows up and they get pain and so forth. So the first thing you do is obviously cut the more offending the the So cut the high peak. Cut the the high peak load. And depending on how severe they are severe they are, you might decide well, that's all they need to do and maybe they can continue with the slower, yep, longer running. Um and in cases where people have a lot quite a lot of pain and you know they're limping, you might need to reduce that load, reduce the running or maybe cut the running for a little while and focus on cross-training. So the so working out why and then and then the first thing you do is cut the offending load. And the offending cut load tends to be that higher load sort of generally it's you know faster running or jumping or hill running. Yep. They tend to be the the the more provocative load. So you tend tend to get those uh cut those out first and then you just keep cutting depending on how they go. As far as pain medications are concerned, not a big believer in using a lot of medication. But I think in the acute phase if someone is in quite a lot of pain they've got a lot of tendon swelling I think it'd be reasonable to you know to to use an anti-inflammatory you could use something like ibuprofen or something a little bit stronger on prescription just need to be a bit careful with um anti-inflammatories non-straudal anti-inflammatories because they do have a lot of side effects and I think you know I think they're underrated uh we need to be a bit cautious about about using them particularly in older patients who might have issues with their hearts or cardiac issues blood pressure issues kidney issues um stomach issues and so forth so just need to be a bit cautious nonetheless I think using short-term and anti-inflammatory treatments icing would be a reasonable thing to do um so that's my priority initially seeing someone in the acute phase and I always try and separate into the acute phase and then the longer term phase so acute phase is shutting them down a little bit getting cross-trained medication potentially and then medium phase is you know getting into the nuts and bolts of trying to get them better.

SPEAKER_02 24:01

Yeah okay cool and so how do you balance that approach with of reducing load but trying to maintain as much activity in them because you know we know that if we've got a runner and we're looking at the lower limb we're looking at Achilles or patellatendon but probably Achilles more so if we pull off load completely we're we're deloading them we're actually back in yeah yeah so we want to keep as much load in as possible. How do you balance that is that just about what you said let's strip back the high load let's see how you know do we do we pull you off for three days five days if you if you've got to get different I think it's a it's a case by case situation.

SPEAKER_01 24:48

I mean I think if you've got someone who is really sore then I think you might need to pull them out completely from impact activity and just focus on um cross-training. Sometimes people can be so sore that they can't cross train as well. I mean that can you know that's obviously rare but but I think it's it's it's a case by case um uh situation I think uh and just just see how sore they are and then just strip away the high loads and then just keep stripping if they're if they're not settling down. Majority of people though with with just stripping them early this is the thing about trying to get them early um before patients get too severe just strip them early and they might be able to continue some of their activity the higher loads and then as things get better then you can just tiptoe back into the into the um the the higher loads. Yep. It's a it's a it's a balancing routine. It's completely we don't always get it right at all. No it's not and we don't we don't always get it right. Yeah things flare up for s for no reason um yeah there are other factors that we may go and talk about as to why you know tendons keep flaring up but as a general rule if you use that principle initially you can get people on a stable footing. This is the way I explain to patients is tendons don't like change.

SPEAKER_03 26:16

Yeah.

SPEAKER_01 26:16

Anytime you change things either up or down they don't like it. So but if you can if you can get on a stable footing with your activity or with your rehab and things are stable then I think you're in a much better place to slowly improve over time. But we want we want minimal change and one of the errors I see I think with patients that present with tendon pain is they've changed things too much. Yeah you know they've decided this is my big bugbear at the moment is Hyrux they decided to do Hyrux uh but not do it once or twice a week they've done it five times a week yeah so things have changed busy what are you complaining about exactly yeah that's true that's true that's true uh but I've never done it myself uh I don't think I could do it but um you know you change you've got some guns on you have a little bit of that I couldn't do it um uh so um so I think you you um you don't you don't want to change things too much I think that's the that's the that's the key and when you're when you're treating people you you also want to keep things fairly stable not change things too much or too dramatically yeah yeah and we'll touch on that with in terms of treatment but yeah old sort of 10% load principle is probably a reasonable adage here.

SPEAKER_02 27:39

Yeah but then when you're training changing your training principles like going from steady running to sprint running you know you've got to consider the amount of force that you're putting through the system is dramatically different at that high speed compared to just you know plodding along. So yeah I I I I think there's an art to actually prescribing the right amount of load. Um okay so tendons as you sort of mentioned there tendons have this optimal window to function in and it's a lot of the time I think it's with our patients it's about sort of okay sometimes with our elite athletes it's deloading them a little bit and then okay building them back up but with a lot of uh non-elites if you like it's about moving that window of function up and up and up would you say that okay if we took out other medical factors movement issues and being under muscled or understrengthed if that's a word are probably two of the biggest factors that lead to tendon issues.

SPEAKER_01 28:56

I think I think muscle is a big factor. Yep I think lack of strength is a big factor. Runners assume that they've got good muscle strength because they're running because they're running but they don't there's been lots of work now done by um some some great uh academics uh in this country looking at uh the Sileus muscle and Sileus muscle is a deeper calf muscle and we we we now classify the Sileus muscle as the power muscle of the low leg. Yeah yeah uh because it is yeah um so I think I I I think a lot of people run into problems because of lack of strength. Yeah I think biomechanics has a role uh I certainly think um you know there is room to look at improving people's biomechanics but I I think strength is a big factor yep and I think if we if we improve strength I think a lot of the pro these tendon problems will slightly improve improve yeah yeah and and I and I think you know in our field in any good physio as part of assessing a tendon okay maybe not in the acute stage when they're hobbling in but needs to be looking at okay well where are their strength markers okay what's their calf loading capacity what's their single leg bridge capacity what can they what's their you know single leg squat movement patterns like and one one thing I've that's that's a really good point but one thing I've noticed certain the last five years is uh and I don't know whether you do this yourself Simon but uh objective measurements yeah and I I like that principle of attendance I like it because you can say to someone look you know your strength compared to someone your age is below normal and you need to improve that yeah um and it not only improves their understanding but also improves their compliance. So you'd say well you need to correct that deficit before you can get back to what you're normally doing to pr to reduce the chance of of getting injured again. So I really like the idea of objective measures. And I've certainly I mean obviously like anything can get overcomplicated.

SPEAKER_02 31:20

Yeah yeah you know we can look at lots of different measures you can look at force platforms you can look at muscle dynamometry we can do lots of things look we we use a lot of that in in our clinic but actually I think some of the most simple things are just functional strength parameters. Okay how many single leg good quality single leg calf raises can you do how many Saleus calf raises can you do what's your single leg squat movement pattern like all of these are really really simple features from a lower limb perspective that actually and we have podium markers we know that I want someone to achieve minimum 25 as a runner of a single leg calf race and so being able to to identify this and then uh age match this or or even show a limb asymmetry will really highlight with people I do have a strength deficit and it's just a really nice marker to go and it and also it also helps with with a compliance factor I think in a big way because you know strength training is not that exciting you know getting into some people love it.

SPEAKER_01 32:34

Some people love it but you know I do a little bit of gym myself but you know if someone said to me look you need to do these calf raises yeah two or three times a week um and it's going to take you two or three months to get better you know they're gonna want a quick fix aren't they're gonna want a quick fixer almost exactly but if you say to them okay your goal is to get to this strength parameter and then we see where you're at with your pain then that makes me feel better yes as a patient. Yeah that's my goal. Yeah so you've got a really specific objective goal really specific objective goal rather than saying just get strong that doesn't mean anything. So I like I like this this this move towards being a little bit more objective with measurements. Yep.

SPEAKER_02 33:17

And as I said you can overcomplicate it a little bit but uh I think a little bit of data is always is good I think for for definitely look we use a lot of muscle dynamometry around the knee in particular we use force platforms in looking at okay jump mechanics but also um how they're loading and landing so I think there's lots of really good tools out there to to give us these objective markers and actually with more and more data out there we're getting sort of being able to get sort of age match normal absolute sort of data for what a runner should be able to achieve and so I think it's pretty easy to see when we have someone come in you know say they're a runner I'll be like okay so tell me tell me about your training what's what's your training oh well I'm running three sessions a week I've got one long run a couple small runs okay what else are you doing? Nothing else a little bit of core maybe not much else and that's the big hole in their training process absolutely absolutely because running does so I think that's a big factor as I mentioned strength.

SPEAKER_01 34:24

It's strength that's and and and also you know biomechanical issues but strength is a big is a big part of that. Yeah not the only part um but I think that's the biggest deficit that I would see in someone who is say not the elite level but we're talking about someone who is maybe a middle aged runner who um has started developing these tendon issues it it comes back to their base strength. Yeah um and that needs to be worked on because if it's not then you just go from injury to injury to injury and I see that a lot.

SPEAKER_02 35:01

So what are some of the key principles in building that capacity back into a tendon? Yeah like this is a pretty we could probably have an hour just discussing this so and this is points.

SPEAKER_01 35:16

So so this is where it can get a bit complicated because and I think I think in my opinion is is becoming overcomplicated a lot. Because I have patients going well I've done these isometrics and I was told to hold them for this number of seconds and I you know it's quite funny because they're listening to uh people speak the language of tendon loading yeah yeah yeah I I like to strip it back and just say as we was talking about you need to get strong. Yeah just get shit strong just get strong it doesn't matter how you do it yeah you just got to get it using the principles that you would do so the way I explained to patients is if I said to you go to the gym and get strong yeah what would you do? Yeah what are the principles that you would use and they would say okay well I'd do maybe a split program and I'd I'd do back biceps one day and I would do uh chest triceps another day I wouldn't work them every day I would do it twice a week probably once or twice a week that's the that's the what you do so so when you're looking at building calf strength that's that's the same principle that you would use so you don't necessarily need to do uh strengthening exercises every single day uh and in fact if we're trying to get calf strength specifically or strength it's probably not a good idea to work your muscle every single day to fatigue um so for me I it's it it goes back to getting just getting as strong as possible and you know whether you use these particular strengthsymmetrics or high load stuff. Yeah I think the principle is that you try and push though and you and I think the biggest error I see in patients that have come to see me say for example an Achilles problem is they've just done body weight calf raises underloaded they're underloaded so if you imagine how much force goes to that Achilles when you run yeah you know we're talking five to eight we're talking about eight times the force and you know you're just putting body weight uh doing calf raises with body weight I think uh so that's the biggest error I see is that they're underloaded and I think you just need to add weight and I and I also encourage people to get to a gym because it's really difficult to put weight on. I mean there are exceptions but most people don't have the equipment at home to to put that higher load on their body or on their on the on their tendon and and cut and calf muscle. And so it can be quite challenging to do it at home. So I encourage people if they can get to a gym it's not absolutely essential but I think it helps. Yeah yeah um also helps with compliance environment yeah yeah so get to the gym do your rehab tendon rehab and then do your other yeah exactly because you can integrate it absolutely you know maintain your cardio all of those other assets absolutely okay so just touching on that point that one of the biggest errors that you see in people's rehab programs is that they are underloading themselves they're not actually putting sufficient load through their tendon with their rehab principles. Absolutely yeah yeah and I think that that's the biggest error that I tend to see the other error I see is that people just exercising every single day. Yeah and I think things have moved on from you know 20 25 30 years ago where we had um the eccentric loading program saying stainish and Kerwin eccentric program Alfredson eccentric program uh you know doing it twice a day really heavy eccentric only yeah and things have moved on from that and we know now that you don't have to do it every day so less is more yeah yeah yeah and I I think there's a lot of evidence that your slow concentric work you know works can be just as effective as that eccentric work but I think you need different aspects of loading in the system so it's not a one size fits all and I've often found that isometrics are good in the early phase they can modulate pain perhaps we can do them a little bit more frequently because you don't get the same level of fatigue in the muscle but then high load exercise you you do two or three times a week and that that's enough then you've got to think about as you're returning you know some playos and jump work and and and that stretch tendon should have that shortening lengthening cycle through the tendon. Again it depends on what the patient wants to do. Like you know I I saw a a lovely elderly lady the other day who wanted to just play bowls yeah so obviously in her situation you know it's it's really a focus on just getting her a little bit stronger. Yeah um she doesn't need to necessarily go through the jumping and the play metric. Yeah. So but but I think the general principle is you need to train what you want the tendon to do. Yes. And if you want to be able to run play football you know jump then part of that rehab program needs to move beyond just getting strong but also imitating what you want to do in in your activity. Yep definitely and I think that needs to be incorporated into particularly end stage rehab otherwise there's a high chance that things will recur. Yes. Yeah and that's is that where you see a portion of people I mean I I break it I think it's I think it's a it's a combination of things but I think I see people breaking down initially because they just not very compliant with you know they're just frustrated and I get I get that I get it. But I do see it at that stage where people have got strength but have then tiptoed back into sport too early. Yeah and it's just a bit too early and then they've developed a flair and they've come in um uh you know with a a recurrence of pain so I think there's you know various aspects of their their journey where they could they unfortunately can drop off a bit. Yeah so we've talked a fair bit about sort of lower limb tendons all tendons seem to have their own sort of unique characteristics but as a guiding rule would you say that we're still underloading the upper limb tendons as well so your cuff tendons I think we are yeah definitely I think I I think I think if you look at the studies that have looked at upper limb and lower limb they're different beasts in a lot of ways I I think rather than saying go really heavy I think there's got to be a little bit um less emphasis on really heavy loads but more emphasis on you know potentially more frequent loading for for certainly around the elbow elbow yeah you want more a little bit more frequent loading so the principles are similar but they're they're not the same so it seems that maybe the upper limb tendons can be loaded a little bit more frequently than than the lower limb tendons. Is that daily that you think you see I mean I think I think tennis elbow elbow tendons probably we're looking at I would always tend to load them daily daily shoulder maybe not so much and again it depends on how irritable the exercises are for patients. But as a general rule upper limb tendinopathy managed slightly differently and I think it'd be good to to see a physiotherapist has confidence in managing the differences between the two.

SPEAKER_02 43:14

As a general rule I'm pretty happy to push someone with lower limb tendon through exercise with a bit of pain. Whereas with the upper limb I'm less happy with with with pain because they tend to remain more irritable particularly elbow stuff and often around the cow I agree with that.

SPEAKER_01 43:35

I agree with that yeah I agree and again the principles are similar but subtly different. Yeah and I think um certainly the studies would actually support what you're saying there. Yep um of of the of the change in in in the rehab yeah okay so but coming on to treatments or interventions

SPEAKER_02 44:00

Sometimes people have had good rehab and they're still in pain. Yeah. So what are our options here? And what are you know, there's such controversy in lots of controversy in in what works, what doesn't, and what we should do.

SPEAKER_01 44:19

Yeah. Yeah. And I and I get it because I've got tendinopathy myself. Yep. So you what's worked for you? Uh what's worked for me? Uh for me it's been it's been consistent loading. Yep. A little bit of shockwave therapy. And then I also had a PIP injection into one of my tendons. Yep. And um, you know, which worked pretty well. Yeah. Uh but I think you need the base. The base is the the rehab. Yeah. And then the other stuff I always call the way I describe it to patients, these are these extra treatments, they're the icing on the cake. Yep. Okay. So if you don't have the cake right, the icing, even if the icing's fantastic, it's not gonna work out. Yep. So we need to get that base right. Yep. Um, I split them into so I've got a few options that I've done to look at. I split them into invasive and non-invasive. Okay, yep. So I always offer patients the non-invasive uh as a way of trying to manage their tendon pain. Um, we've got something called shockwave therapy, which I think is good treatment. Yep. I mean, I think you know, certainly the studies are mixed. Yeah. They haven't shown positive results in all the studies, but overall there's been some benefit of using shockwave. Thing I like about shockwave is it's non-invasive. Yeah. And there's no real downside. Hardly any downside. Like, yeah, people can maybe get a flare, but a little bit of a flare for a short period of time. And I think some people really respond to it. Now, uh, I know some of my colleagues will argue, well, it's just placebo.

SPEAKER_02 45:54

But I mean you there's no doubt, and we use Shockwave a lot for lots of the different tendons and different stages that we've discussed. There's no doubt that in most of them, you'll do a pre and post-test and you'll have generated an analgesic response.

SPEAKER_01 46:11

Absolutely. I agree.

SPEAKER_02 46:13

So, what is that? That's that that's that's a response that's not placebo. That that's a uh, you know, a response that does it shut down the the the tendon, does it shut down the receptors, does it alter?

SPEAKER_01 46:27

I I'm not sure where uh I've knowledge enough to discuss. I I think the evidence suggests that it has multiple effects uh both on the tendon and also on the nerves that that innovate the tendon. So we're shutting down the nerves and we're potentially remodeling the tendon or or or changing the structure of the tendon. Yep. Uh I I I see very little downside with it, and I like using it because a couple of reasons, because I think it does have a positive effect. Second reason is it keeps people entered not entertained, but in in in in understanding that this is for their rehab. So I always say that shockwave is an injunct, it's not the sole treatment and shouldn't use it as a sole treatment. Yep. Um, so it it um it keeps them on board. Yeah, yeah. Uh and if I do I do some shockwave, I uh I send them to a lot of physias like your center um to to do the shockwave. But I I would do it a little bit myself and you know you always have a little chat as you're doing a shockwave, how things are going, you're doing your exercises, you know, reminding them of the importance of that, they're having an issue, you might chat about the issue. Yeah. So it just keeps them on board with you know doing the exercises. And engaged. And engaged. Yeah, that's a good word, engaged.

unknown 47:45

Okay.

SPEAKER_01 47:46

So the the shockwave therapy, the other the other um treatment I use is uh something called GTN patches. Yep. So again, controversial. There were there's a big vogue for those.

SPEAKER_02 48:00

Fifte, twenty years ago, maybe.

SPEAKER_01 48:02

So, you know, a colleague of mine in Australia did the first study on GTN patches. So what is GTN? GTN is glycerol trinitrate. Yep. And we use GTN patches for people with heart disease to open up their blood vessels. But in fact, nitric oxide, which is the active component of GTN, um, we also know is an important metabolite in tendon uh uh repair and and and so forth. And so adding nitric oxide, the hypothesis is we're enhancing that repair process. Um the initial studies were very promising. Yep subsequent to that, it's been mixed, and certainly there have been reviews, systematic reviews, we call them, that have found some rev systematic reviews have found positive results, uh, some not so positive. Yep. But again, like shockwave therapy, the good thing with GTM patches is there's little downside. I mean, you do have some side effects and you need it needs to be prescribed by headaches the big one. And the why the way I mitigate that is to cut the patch in a quarter milligram. So five milligram, you need to use the brand Depinit. Yep. Um, because if you use the other brands and cut them, they leak out and gives you a massive headache. Yeah. Uh so you use a particular brand in in this country and you cut them into a quarter. So the way I do it is cut them, cut in a into a quarter, use that for four days. Yep. And then if they're tolerating the quarter, then go up to a half or four days, and then a full patch after that. And if they can't tolerate yeah, I still use full patch if they're tolerating it. Yeah, yeah, yeah.

SPEAKER_02 49:44

Yeah, yep, yep. So and uh any particular tendons that you're finding a more responsive.

SPEAKER_01 49:52

I find it I find it well any of the superficial tendons. So looking at Achilles, uh telotendon, tennis elbow, not so much for the t for the shoulder. Um, and the deeper tendons. I wouldn't use it, but um certainly for the more superficial, not so much for plant fascia because it's quite deep. Yeah. But I find it, you know, some people respond really well to it. Okay, cool. And I think it's a good way of trying to get people over a hump if they're stuck, yeah. Uh without taking uh undue risks. Yep. Um so they're the non-invasive ones, then you've got the invasive GTM patches. So the invasive tend to be injections. Yep. Uh and so they can be split into different groups. Um, so traditionally we use cortisone. Yep. Um, but um certainly recently there's been a drive away from cortisone because I we know cortisone has potential negative effects on tendons. Yes. And certainly in my practice over 20 years, I'm finding the number of injections, cortisone injections that I'm doing for tendons is dropping. Yeah. Uh for overall, uh, for even for joints, it's is dropping as well. But certainly for tendons.

SPEAKER_02 51:02

People are more reluctant to I don't know whether it's a recent thing, but they're they're they're like, no, I want to I want to keep it natural. I I I don't want to do anything. So they're more amenable to yeah, either a GTM patch or shockwave therapy, or like just working through rehab, if you've given them a good understanding of what's going on, they're like, no, let's let's let's work through this for six, eight weeks first, which I think is the is is the right approach most of the time.

SPEAKER_01 51:34

Absolutely. I think as I was mentioning before, slowly, slowly wins the race. Yeah. As soon as you hit that injection button, then there's a massive amount of um unpredictability that occurs. So, you know, you you could have a fantastic response, or you could actually get worse. Yeah. And I think people don't appreciate the fact that as soon as you intervene with some in something invasive, either injections or surgery, there is a risk that you could actually get worse. And I think that's not an insignificant risk. Yeah. Um, so as far as injections are concerned, certainly cortisone has been used less and less, and so it should be. Um is there ever a role for it? I mean, I think it depends on the tendon. Yep. And I think there are exceptions to the rule for sure, uh, with with any tendon, but overall I I tend not to use cortisone for the bigger tendons, Achilles and Patella tendon, uh, less so for the hip tendons. Yes. Certainly using it a lot less. Um, I still use it on occasion for the shoulder. Yep. You know, rotator cuff tendonitis. Yep. Um, but um not so much for the elbows either, because I think there's some good evidence that cortisone might lead to a a lip tear or something. Well, could could make you worse. And in fact, there was a study some studies done um certainly in the last 20 years that have shown that if you have a cortisone injection from tennis album, you'll do worse than not doing anything.

SPEAKER_03 53:06

Yeah. Yeah.

SPEAKER_02 53:07

I think there's also it's a BJSM News Journal of Sports Medicine that showed that actually you inject, you're better, and then six weeks you you you you know better than doing nothing.

SPEAKER_01 53:19

Yeah, exactly. Or you're worse than doing nothing. Yeah. That's what happens. It actually at six weeks the the your pain levels can can drop off. Can drop off, yeah. And you can actually do worse. And you you you you don't and that can be last for up to a year. So I always tell people, um, I it's a bit of a joke that I say, but I say, you know, if I if I don't like you, I'd give you a cortisone injection for your tennis elbow. Yeah. Yeah. Because I think there's a good chance that um you'll do worse. Now, does that mean no one should have a cortisone injection tennis? No, I'm not saying that. There's you know, exceptions to the rule. And you know, I've I've I've met people that, you know, building a house and they need to to be pain free for four weeks, or they have exams and they've got m you know severe tennis elbow. You know, I think it'd be reasonable to give them sometimes you need to get people out of pain. Out of pain. Yeah. And and you know, I think there are exceptions, but as a general rule, I think we need to avoid cortisone injections as a general rule for most of the tendons. Okay. So the movement now is towards other injections, such as PRP, which is PRP is platelet-rich plasma. Platelet-rich plasma. So we take your blood, and then we spin it down into a tube, and so you get your your heavy cells, which are your red cells, blue and white cells at the bottom part, and then your plasma, and the plasma has the light the smaller cells called platelets. Yep. And these platelets have um lots of growth factors. Uh and you inject the theory is, or the hypothesis is you inject PRP into a tendon, and it has some sort of chemical reaction, um, which then enhances healing.

SPEAKER_02 55:05

And it's almost, you know, that is almost a pro-inflammatory approach. So to stimulate a healing response, whereas the cortisone is almost the opposite.

SPEAKER_01 55:15

Yeah, it's to reduce to reduce the inflammatory process more. So the way I explain it is it resets the tendon. So you inject it in, resets a tendon, but you need to do rehab after to get the maximum benefit. Yeah. So as a general rule, I think you need to be cautious about PRP because I think it doesn't make everyone better. And there are certain tendons that maybe you might focus on a little bit more, like um, I think PRP works better for um the elbow tendons and um the hip tendons, hamstring tendon like mine. Um I think it that that's my preferred target. Uh Achilles patella tendon, not so convinced that PRP is effective. And is that because they are different in structure and we don't really know, but probably it's probably uh a case of they're just different types of tendons and they just won't respond to in interventions as well.

SPEAKER_02 56:18

So PRP and it depends on the branding that you're using, I think, can be a one-off injection. Some people repeat it multiple times. Sure. Is that just based on experience? Is there are there any hard RCTs out there?

SPEAKER_01 56:42

I mean the evidence is a little bit um controversial. Yeah. But as a general rule, the the the theme is that the higher the concentration of platelets, potentially the better the response that you get from uh a PRP injection. Um, but again, quite controversial. Yeah. So certainly in my practice, I try not to do PRP injections, but if I'm doing a PRP injection, I would look at something that is more of a one-shot higher concentration PRP. Yep. Uh again, you've got issues with insurance companies not covering that, or you might have to go with the standard PRP. But as a general rule, I think the trend is moving towards a higher concentration, one-shp, which is great because it means less injections. Yes. So rather than having three injections, you can just have just have a one-shot injection.

SPEAKER_02 57:36

And do you like to sort of delo the patient for a short period after that?

SPEAKER_01 57:41

Yeah, not too not too much of a um uh arrest. Again, it depends on what we're doing exactly. Certainly for the Achilles and Patella tendon, if I'm going to be doing a PIP, I would tend to deload them for about a week and then get them moving again fairly quickly. Again, depending on whether they get a reaction or some people get a flare after the injection, so might need a bit longer. Yeah, okay.

SPEAKER_02 58:09

So a lot of tendons. Some tendons can go on to become very chronic and really problematic and grumpy. But is how much does our hormones and metabolism play a role in perhaps a lot of these chronic sort of tendons? Is you know, we spoke and alluded to this at the start, that there's often a lot of other factors. Yeah. Rule out okay, someone being under muscled and the biomechanics are sort of alright.

SPEAKER_01 58:45

Are we looking deeper at these systems? I think thing things are moving ahead as far as you know, trying to find the cause or the drivers, potential drivers. We're not just looking at you know, strength and overload and biomechanics, we're also looking at other factors. Yep. Disease processes that people can have. I alluded to this before, cholesterol, high cholesterol.

SPEAKER_02 59:07

So high cholesterol is is one key factor often linked to tendon pathologies, isn't it?

SPEAKER_01 59:14

Definitely. Yeah. Yeah. So in people that have disease processes where they have a very high cholesterol for genetic reasons, they have more tendon disease than than people who have normal cholesterol. So diabetics are more prone to getting tendon disease. Uh-huh. Um, if you've got people that are overweight, um, certainly that that is a is a factor. Then there's other other disease processes such as inflammatory arthritis, uh of various, you know, rheumatoid arthritis, uh, and a lot of those other um uh disease processes can predispose to developing tendon disease. Gout is an important one in men, particularly. So gout's a tricky, it's a tricky disease, and it can present diagnose at it's sometimes it's almost a clinical. Yeah, sometimes I've diagnosed gout with patients who are presented with acute Achilles tendon pain. Yeah. And it's that's their first presentation is gout. So we need to be thinking about whether it's the primary driver or maybe a secondary driver. So people that have high um uric acid levels, which cause gout, um, are also at risk of developing or potentially as a it's a potential secondary driver of tendon pain. Um and menopause. Yes. So, you know, women that are menopausal or perimenopausal. Because oestrogen's a really important hormone for tendons. Yeah, so certainly there's studies now looking at you know if we can supplement that with either HRT or maybe even topical um hormone treatment, uh, will that have a positive effect on on tendon pain? And you know, there's certainly some studies at the moment looking at that very factor.

SPEAKER_02 1:01:06

Yeah. Just thinking out loudly here, GLP1 agonists. You know, we we think they're probably having an impact on that low-grade systemic inflammation. A lot of what drives our disease process perhaps is linked to to that. Systemic inflammation. Yeah. And it's been remarkable a lot of the changes that we're seeing coincidentally with people who are having on GLP ones. And you know, all of a sudden they're they're less anxious or they're less in less pain. And it's quite hard to understand what uh the the drivers are there.

SPEAKER_01 1:01:56

Have you seen this as well? Absolutely. Yeah, I think it's very, very interesting what's happening with now with people on these medications. I'm not necessarily advocating people going on these medications, but do you use them for patients ever? I I I don't, and I I refer them back to their GP, or um, but I know colleagues of mine who are using them as part of that treatment option. And I think you know, um I probably will move into prescribing it for patients who um obviously have uh who qualify for the drugs. You have to have a certain BM BMI. But so but certainly um what I've seen interestingly, and just very anecdotal, and obviously I don't have any data for this, but certainly people that are on it who lose weight also find that their shoulder pain improves, their knee improves, the Achilles tendon improves. And they've done studies on um on on uh weight loss, and they found that actually it's the most important factor is not the weight itself, yeah, but the fact that you know the systemic inflammation reduces and it's that reduction the quality of the tissue almost. Yeah. So fat is very inflammatory. So if you get a lot of fat, then that spews out a lot of inflammation, and then that then moves to different parts of the body, moves to the Achilles, moves to the knee joint, moves to the heart, and you get the damage occurring and increased inflammation. You remove a lot of that fat, then you get a lot of less inflammation. So it's actually the weight loss is partly due to reduction in weight, but but also I think more importantly, due to reduction in systemic inflammation, which we know has a positive effect on our tendons, yeah, as well as our heart, you know, blood vessels and so forth.

SPEAKER_02 1:03:49

So looking at someone very holistically, discussing their sleep, discussing their diet, yeah, looking at all of these other factors has got to be really critical.

SPEAKER_01 1:03:58

Looking at the alcohol intake. Yeah. You know, looking at whether they smoke. Which is a big inflammatory driver.

SPEAKER_02 1:04:03

Yeah.

SPEAKER_01 1:04:03

Smoking, huge inflammatory driver. Yeah. You know, so alcohol, smoking, weight, yeah, uh, and and you know, sleep and stress levels and so forth. So looking at holistically, so we've got a tendon, inflamed tendon, but then you're looking at the patient from a holistic perspective and and focusing on the other areas that might actually help other parts of their body as well, including their mental health.

SPEAKER_02 1:04:31

Yeah, very yeah, interesting point that one. So could tendinopathy almost be considered a sus almost part of a systemic issue?

SPEAKER_01 1:04:41

Yeah. I always I always say to people, it's a bit of a warning sign if you do get tendinopathy. You know, maybe maybe you need to think about rather than just being tendon disease, yeah, think about you know, something is not right systemically. Yeah. And it it it there may not be anything wrong. Yeah. It might be a pure overload tendinopathy, you know, you've done too much exercise and the tendon swollen. But I think you need to look at other, you know, possible drivers. And it's important to, you know, if you do find them, to treat them. Yes. Um, treat them early. Yep. So they don't become a problem. You don't become diabetic. Um, I mean, there's so many other consequences of you've got high blood pressure, you know. You need to treat that to reduce heart disease and and stroke. Um, you know, weight gain is a is a big factor. Yeah. Um, so I think it can almost be seen as part of a systemic disease process rather than just a single swollen Achilles tended.

SPEAKER_02 1:05:47

Yeah. Yeah. So you touched on menopause. Now we often see that the same individual. Will present with multiple tendon pathologies during that peri postmenopause. How critical are are the estrogen hormones or testosterone hormones to tendons?

SPEAKER_01 1:06:17

And I think I think the jury's out with testosterone. Yep. And I think um I don't think there's any good data to suggest that testosterone replacement improves tendon health. But certainly we know that women who are menopausal are more likely to develop tendon disease and then they're more likely to be difficult to manage. Yes. And so it tend to set the expectations accordingly. However, what we don't know is whether HRT improves that or not. So people ask me about this. People ask me about this about HRT. Should I go on HRT? I've got tendon disease. Should I should I replace? I always say, look, I think you need to look at the other potential benefits and risks of HRT. And I know there's now a drive for more women to be on HRT, which I think is a good thing. Yep. And I said I I always say to them, look, say to women, I think if there are other reasons for you to be on HRT, I think it can only be positive for tendons that you are on uh HRT, uh, because I think it will help your tendons, although I don't have you know major good data to suggest that, but it makes sense that they will. It's certainly not negative. Um, it shouldn't be the only factor, though, I think, yeah at this stage. Yeah. I mean things might change with research, but it's it shouldn't be the only factor. But I think if you need HRT for other medical reasons, symptoms or other medical reasons, then I think it's it's probably gonna be a benefit for you. Yeah. Okay.

SPEAKER_02 1:07:48

So we could chat for a long time about all this, and uh unfortunately we've got to sort of start wrapping some of this up. Okay. But because I know you could you could keep talking. I keep keep talking, yeah. Um, and I've loved it because it's been super fascinating to sort of dive into this because they are tricky. And they are tricky, and they are often very multifactorial. And I think you know, one of my biggest takeaways from listening to you today is that we've got to think very, very holistically about something. We've got to almost consider that tendon pathology as a systemic condition and look at the hormone levels, their metabolic health, what else is going on? Are there stress drivers? What's their diet like? Um, all of these factors um that might contribute. But if you had to give a couple of key, two or three key um ingredients for someone un trying to go through some tendon rehab, what would they be?

SPEAKER_01 1:08:56

Uh keys for me would be just get strong. I think that's really, really important. Yep. Um I think I think mix it up. Yep. Because I think people just lose interest. Yeah, yeah. Um get bored. Yeah, yeah, yeah. I think mix it up. I think speak to your speak to your therapist about, well, let's mix this up a little bit and see whether we can get more gains by doing something slightly different, yeah, rather than doing the same thing all the time. Um and and just think about slowly, slowly wins the race with tendons. So people want to be better. Really selling it, uh they want to be they want to be better yesterday. Yeah. And I always say, you know, you've just gotta just gotta chip away at it. And then if things aren't going well, if they're plateauing or they're regressing, then we can talk about other treatments. Yeah, you know, talk about the invasive treatments or non-invasive treatments as we discussed. Yeah. But I I'd like to get on that road of thinking about just slowly getting better over time.

SPEAKER_02 1:10:01

Consistency is key. I think that was you know, I I was part of a longevity panel on the weekend, and one of the biggest things was that okay, exercise is such a foundational aspect to that, but actually, consistency is just the key thing. Yeah, you know, don't aim for up here, aim for just being consistent down here. I think that's the same with tendon pathology. Absolutely.

SPEAKER_01 1:10:25

Um, doing the good stuff well consistently, and all the extras are fine. Um, but if you don't have the the the basic the the basic ingredients there, yeah, it doesn't matter what you add. It doesn't matter whether you have injections, uh stem cell injections, peptides now, everyone's talking about peptides. Yeah, all that stuff is just that's the icing on the cake. Yep. Um you need to get that cake right. Yep, agreed.

SPEAKER_02 1:10:57

Okay. Amazing. Lorenzo, thank you so much for your time. Thank you for having me. It was super cool to be good. Probably do a part two some maybe. Excellent. Love to be back. Thank you. Thank you.