Tendon Pain and Rehabilitation Explained by Prof. Peter Malliaras

Tendon pain is one of the most common musculoskeletal conditions affecting both active individuals and the general population, yet it remains widely misunderstood.

In this episode, we sit down with Professor Peter Malliaras, internationally recognised physiotherapist, researcher, and one of the world's leading experts in tendinopathy, to explore what we now understand about tendon pain, rehabilitation, and recovery.

Drawing on decades of research, Professor Malliaras explains how our understanding of tendinopathy has evolved beyond simply viewing it as tendon damage, towards a broader understanding of tendon capacity, adaptation, and function.

A key focus of the conversation is the relationship between pain and imaging. We explore why tendon scans often don't correlate with symptoms, why structural abnormalities aren't always the cause of pain, and why rehabilitation should be guided by clinical presentation rather than imaging alone.

We also discuss why load is one of the most effective treatments for tendon pain. From determining the right starting point to understanding how much pain is acceptable during exercise, Professor Malliaras explains why complete rest is often counterproductive and why successful rehabilitation is built around individualised loading rather than rigid exercise protocols.

The discussion extends beyond biomechanics into the growing influence of metabolic health and hormones on tendon health. We explore why clinicians should increasingly think beyond the tendon itself, and where treatments such as shockwave therapy and PRP fit within modern evidence-based care.

Finally, Professor Malliaras shares practical advice for managing tendon pain early, the biggest misconceptions surrounding tendon rehabilitation, and what excites him most about the future of tendon research.

🎙️ In This Episode, We Cover

• What tendinopathy actually is and how our understanding has evolved
• Why tendons heal differently from muscles
• Why tendon pain doesn't always match MRI or ultrasound findings
• Why load is one of the most effective treatments for tendon pain
• Isometrics, eccentrics, and heavy slow resistance explained
• How much pain is acceptable during rehabilitation
• The influence of metabolic health and hormones on tendon health
• When shockwave therapy and PRP are appropriate
• The biggest myths surrounding tendon pain and recovery
• Practical advice for returning safely to activity

🎯 Who This Episode Is For

• Anyone experiencing ongoing tendon pain or recurrent injuries
• Runners, athletes, and active individuals managing tendinopathy
• People recovering from Achilles, patellar, gluteal, or hamstring tendon injuries
• Physiotherapists, sports medicine clinicians, and rehabilitation professionals
• Anyone interested in understanding the latest evidence surrounding tendon rehabilitation

🎙️ Powered by Mayfair Health

At Mayfair Health, we specialise in recovery, performance, and proactive wellness. Whether you're recovering from injury, returning to sport, or looking to better understand how your body adapts to training and load, our multidisciplinary team is here to help.

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

SPEAKER_01 0:00

Hello, all, and welcome back to another episode of Move Well, Live Well, Perform Well. I am super excited today because we're gonna discuss all things tendons. And we've got an amazing guest lined up. We're gonna discuss why tendons are so tricky, how to try and optimize their loading, and do any passive treatments work? And what do we need to do to understand some of the pathophysiology of tendons? Um, and how do we get to grips with uh treating them more effectively? Because they can sometimes be tricky. So, our guest today is uh Professor Peter Maliaros. He's an internationally recognized physio researcher and educator specializing in tendon pain and rehab. He's Aussie, of course. Um tendonopathy with a career dedicated to understanding the relationship between tendon pathology, pain loading, pain loading, and recovery. His research has significantly influenced how clinicians assess and manage tendon conditions, helping shift the field away from passive treatment approaches and towards evidence-based loading strategies. Peter has published successfully on Achilles, patella, gluteal, and ham and proximal hamstring tendonopathy, and is particularly known for his work exploring the complex relationship between imaging findings, tissue pathology, and patient symptoms. Through his research, teaching, and clinical work, he continues to shape international best practice in tendon rehab, helping clinicians better understand why tendons become painful, how they adapt to load, and how patients can return to active activities safely and effectively. Thanks very much, Simon. Thanks for having me. No problems. Well, Peter's kindly got up and run to work just testing out his Achilles tendons first thing in the morning in in in Melbourne, Australia here. Um so yeah, thank you and welcome.

SPEAKER_00 1:59

Yeah, no, thank you. Thank you. It's great to be here.

SPEAKER_01 2:02

Pete, we're gonna dive straight into some little bit of introduction about tendons, because you spent a lot of your career studying tendon pathology, but they're pretty tricky, and what makes them so different to sort of managing different muscle pathologies?

SPEAKER_00 2:22

Yeah, it's a good question. So I think the uh the hardest thing about tendons, and uh this may be similar in other areas because I'm not uh on top of or aware of other areas, but the hardest thing for me about tendons is they're it's it's they're so heterogeneous. Yeah. Uh yet we we see you know it's such a different mix of people and different presentations and uh things that you have to address to get them better. And uh, you know, we sort of treat them all or have historically in a very similar way, and it just doesn't work. And um we're realizing that now. So there, you know, it why people have pain varies a lot between person to person, and we need to appreciate that to get people better.

SPEAKER_01 3:15

Yeah, okay, cool. So so the really the you know tendons are all very different and the and how they present of are quite different, and we can't really have that one size fits all um approach for them. That's sort of what you're suggesting.

SPEAKER_00 3:31

Yeah, exactly. So there's yeah, we can't have a one-size-fits-all approach. We need to look at the individual and we need to understand what is it about that person that we need to influence the most to get them better. And it's that's a tricky, tricky thing. And I think what we do is we go down the path of okay, let's just do this protocol or that protocol instead, because it's easier.

SPEAKER_01 3:56

Yeah, yeah, yeah. Okay, so what what's the primary role of a tendon? Uh and why are they so important for sort of human movement and performance? Is it sort of a load transfer that that they're responsible for? Is that the key role, would you say?

SPEAKER_00 4:15

So the key role of tendons is to it's a connective tissue that connects the muscle to the bone. So it tra it the really the key role is just to transfer forces from the muscle to the bone. Now, it also has a second very important function, and that is to store and release energy. So when we're doing human movements like walking and running in particular, it will store energy, and particularly tendons in the lower limb, in the leg, will store energy. Now, what happens is um uh because it's able to store energy and release energy, it provides part of the energy requirements for us to move as humans, so therefore it makes us much more efficient, and that's a very, very important function as well. Now, in sports contexts, it can also make us more powerful so we can produce more power. So, so tendons have those very, very important roles to play, and that's uh we also see that the tendons that do that type of activity are the ones that get injured more.

SPEAKER_01 5:26

Yep. And are you uh still referring, is that more the lower limb tendons that have that that or do all the tendons through the upper limb s still have uh those two different functions?

SPEAKER_00 5:42

Yeah, the upper limb does as well, but it's it's different because they don't have it's not so much related to impact. So you don't do impact stuff where you're landing on your arms, uh or you know, at least not very often, but um you do throwing, and throwing is a stretch-shortened cycle activity as well. So it it just is a little bit different, it's more open chain in the in the upper limb as opposed to the lower limb.

SPEAKER_01 6:08

Yep. So how has our understanding of tendinopathy changed over the last 15 or 20 years? You know, I I I was at La Trobe Un University with Jill Cook uh many, many moons ago, and I I know you've worked uh with Jill Cook pretty closely, and she was probably m you know one of my guru's lecturers back in the day and started off my sort of appetite for understanding more about tendons. Um was she one of the early pioneers in in evolving our thinking? Do you do you feel?

SPEAKER_00 6:49

Absolutely, yeah, absolutely. So um I think if you look at the history of tendinopathy back in when we first started learning about these conditions, we're thinking inf inflammation within the tendon. Uh so you just need to take some anti-inflammatories and rest and you'll be better. And then uh people like Hocken Alfredson Jill Cook uh changed that. Uh people like Nick Nicola McFooly as well, where they started researching tendons and also Karim Khan back in those days, researching tendons, seeing that um actually it's not that not that simple. Uh there's a lot more going on. Um, and it's not just about uh we we started learning that anti-inflammatories anecdotally don't really work that well. Uh, we started learning that um uh maybe there wasn't just this simple inflammation that you just need to take you know rest for. Uh and then um you know they started investigating other ways of treating it. Now, if we go back to the 80s, uh, which is not long ago, um uh I um I uh wasn't a physio, then I started being a physio, when was it? Uh 1997, I think it was, but just before my time in the in the uh late 80s, early 90s, whenever you saw an a pathology in the tendon, a surgeon would then cut it out. Yeah, they debrite it. Debride it, or just even remove that pathology completely. So so we've come a long way from uh from that, and it was just a realization that there was two probably key things that changed. One, uh we understood that pathology does not equal pain. Yeah. Uh and that was a lot of Jill Cook's and Karim Khan's work.

SPEAKER_02 8:42

Yeah.

SPEAKER_00 8:42

Then the second thing was we understood that it's not going to be something we treat basically with just rest and uh anti-inflammatories. Uh, and then we started all the uh approaches that we currently now are still investigating, which is exercise and other adjunct approaches. Yep. Cool.

SPEAKER_01 9:02

Okay, so we've changed quite a lot in in that in that sort of 20-odd, 30 years, um 40 years plus now. Um and we we tend to now use rather than tendinitis, which people still sometimes use, but we tend to use the word tendinopathy. Um so what are we actually meaning when we're using that terminology?

SPEAKER_00 9:30

Yeah, so um what we what what so we know that tendinophthy these days is the term that we use. We don't we don't use tendinitis and we don't use tendinosis. Uh we've gone away from those terms because they imply a specific pathophysiology that we just don't really have any evidence for uh as being a universal thing, and certainly when we see a patient in clinical practice, we don't have any evidence for those things. Uh so all we can say is that they've got some sort of opathy, which is a painful or dysfunctional condition of their tendon.

SPEAKER_02 10:07

Yeah.

SPEAKER_00 10:07

Um that could be pain or pathology, so it's very broad tendonopathy, the term. Uh so that's what we use. Now, what what it basically means is is anything uh painful in the region of the tendon. Yeah, okay. That's that's really what yeah what we're referring to.

SPEAKER_01 10:25

And because a lot of the time, and I'm sure we'll get to this, you know, we can we can see tendons that are painful, but they don't have much pathology. Yet we can see lots of pathological change within tendons. Actually, they're they're they're not very painful at all. So that you know, equates to what you were saying earlier, that pathology does not equal pain a lot of the time.

SPEAKER_00 10:53

Yeah, yeah, exactly right. Yeah, so it there's a big mismatch. So uh you what we used to do is say, okay, go and have an MRI scan or go and have an ultrasound scan, and that will tell us what your diagnosis is. And MRI, don't forget, MRI has only been around for you know 20, 30 years, really. And uh it was a big, a big advance in those days, and people thought that it was gonna, you know, tell them what where their pain was. Uh, but now we know that uh whenever you have imaging, lots of people have changes on their imaging that really is not relevant and uh doesn't show us anything that is new or relevant or uh the source of their pain. So what what we our our current thinking is that uh whatever the pathology is on ultrasound or on uh MRI, it's uh it's not necessarily related to that uh person's pain. And it's even if it is related, and this is the probably the key point, um, even if you've have a tendon pain that you diagnose clinically, and then uh you have a scan, an option on MRI, and you see that there's also pathology there. Uh, what we say to patients these days is that the pathology that we're seeing on that scan is not the cause of your pain. It's just confirming you've got a problem there. But the underlying stuff that we don't see, so the stuff under the hood, is the all the biochemical changes that are occurring within the tendon. They're the things that are sensitizing the tendon most likely likely causing pain.

SPEAKER_01 12:41

So what biochemical changes are we assuming are happening? Can we assume that there's specific biochemical changes that are occurring when someone has a painful tendon that we can't see?

SPEAKER_00 12:59

Yeah, so um the current thinking is around um cell signaling. So the cells start to activate, they start to produce signaling pathways, multiple signaling pathways. Yep. Um you start to get immune responses, you get uh cytokine pathways activated, you get uh you get changes in some of the neurotransmitters and neuropeptides in the area. So um there's neural changes, there's cell changes locally, and there's immune changes. Yep. Uh and it's a combination of factors that then sensitize the tendon. And that's probably why if you touch a tendon, it's quite tender when it's painful, when someone's got a painful problem, and it's because of that, uh, those changes occurring there. Uh, but they can be uh overlapping with the pathology that we see, but sometimes they can also be separate because of the pathology that we see as well.

SPEAKER_01 13:56

Yeah, okay. So fascinating. So the can you explain sort of the continuum model of tendonopathy and why this has been fairly influential in um the tendon research?

SPEAKER_00 14:16

Yeah, yeah, yeah. So it certainly has been very, very influential. Uh it's um the continuum model was put forward by Jill Cook and Craig Pertham in 2000. Oh, I'm probably gonna get it wrong, but 2009, I think. And um basically what they put forward was a three-stage process for how tendon uh pathology develops. And the first stage is um a reactive stage where the cells activate and they uh produce, they they start activating and producing um uh extra material, and that's mainly the proteoglycans, which are proteins that bind water. So you start to get this increased thickness of the tendon, which is water being drawn in. Uh, but at that point the collagen matrix is still okay. Then you go into disrepair where you start to get changes in the collagen matrix, uh, and then you go into um and then you go further into uh degenerative, the last stage, which you start to get changes and pockets of sort of you know, degenerate or tissue that is very poor quality with ingrowth of blood vessels and nerves. Yep. So that's uh So that neovascularity. Neovascularity, exactly, yeah. So so that's that's the three stages, and um uh it's a very, very I I I still think it's a very good pathology model. So it tells us it tells us tells us a lot about our um tells us a lot about uh what uh are the stages of pathology. But it's it's uh what I think the the biggest issue with the continuum model is that uh as we've talked about already, those stages do not necessarily have anything to do with pain. Yeah. So uh so that there is a disconnect between the pain that we see and the pathology still. But I think there's some truth in the model in terms of uh how it describes the progression of pathology within. Okay.

SPEAKER_01 16:28

Okay. So coming on to um of the the way that we're looking at tendons, I I think we've sort of moved away from a structural approach to tendonopathy. And we're sort of moving towards more of a tendon capacity um model. Is would you agree with that?

SPEAKER_00 16:52

Uh depends what you mean by tendon capacity.

SPEAKER_01 16:56

So um so I think So I suppose in looking at okay, are we uh are we assessing um or giving diagnosis to a tendon based on okay, their capacity to tolerate load and the stage of perhaps pathology or the stage of um pain that that particular tendon is in rather than a purely structural view of that tendon?

SPEAKER_00 17:30

Yeah, I think I think so. I think so. I think if you mean capacity is in a surrogate for how much pain tolerance the tendon has, then I think that's true. I think we've moved to a model now where we uh look at uh, you know, the the primary sort of thinking or the way that we manage them is to first say, okay, how much pain do you have with day-to-day activities, loading, all those things, and uh then we manage accordingly uh depending on that symptom, and that will then dictate some of the things that we do. Um, so how much loading we do, how we progress the loading, maybe how much we manage some of the other activities they're doing that might be contributing. Um that all comes down to pain. So, yes, that that is the approach. Uh, but then there's also the the I think the biggest and most important thing in that is to work out why they've got the pain. Yeah. What's the drive what are the drivers? What are the drivers for that pain? Yeah, exactly. Yep.

SPEAKER_01 18:31

Yeah. And and we'll touch on these i i i in a minute potentially. Um maybe we can dive into it now. Uh you know, are you looking at when you're assessing a tendon or someone with tendon pain, are you looking at you're looking at, okay, their mechanics, their ability to tolerate load, their strength capacity through their through their posterior chain, through their core length, tension. And then also what their hormonal processes might be going on, what their metabolic health is is like, and also from an immune response perspective, because we know that there's a cytokine reaction often that can occur within the biochemistry of cells as well. So you're looking at these sort of multiple systems to try and understand how big a factor of each of those might be driving the tendon pain?

SPEAKER_00 19:36

Yes, yes, yes, all that stuff. So all so basically um it's looking at um it's looking at uh trying to understand um trying to understand how um that person has got there basically. So is is there was there some sort of um activities or some other things that have changed in that in the history of that person? Uh or are there other things that are more relevant for them, like um, you know, for example, life stress or uh circumstances rather than loading changes. Uh so what has brought about their pain? Just remembering that when they have the onset of pain, it might be months, weeks, or years prior that they had the onset of pathology. Yep. So um so pathology and pain are disconnected in terms of onset. And um uh so so so we're looking to understand what what has been the driver for their pain. And it's all the factors you've talked about. Basically, we clumped them into probably three groups or four groups. Um one is uh things that are systemic, like endocrine, uh endocrine, metabolic, and inflammatory drivers, things that are psychological, like thought processes, cognitions, emotions, catastrophizing, fear, all those things. And then things that are um things that are very physical, load related. So, you know, someone can have very load-related pain and be an acute flare-up, and that's probably the closest thing you're gonna get to a reactive in the reaction in the continuum model.

SPEAKER_01 21:18

Um and then there's also people that that one sorry, Pete. That one there is almost the you know, someone who's not running suddenly goes out and decides to run a marathon and wonders why their Achilles sort of blows up. That's the typical okay, reactive tetnadopathy that you're sort of talking about there.

SPEAKER_00 21:38

Exactly. Exactly, yeah, that's right. That very cute onset from a very clear low drive change or driver. Uh and then the last category is uh people who have uh some pain sensitivity or nosoplastic pain. Now, of course, all of these categories can uh interact and they feed. Yeah, they they they basically you know some people have elements of two or three. So that's the that's the but it's helpful to think about all these domains that we look for uh and we assess for the all those domains just to see what is the most dominant thing or what do we need to really address for that person, and that's how we would really approach it.

SPEAKER_01 22:23

Yeah. So the level of complexity in terms of looking at tendon pain, and w it feels like we're we're moving, you know, a lot closer to thinking about, you know, central sensitization with with tendon pathology, you know, that that fear-avoidant behavior and catastrophization, um, as well as you know, different immune responses within tendons as well. And it's not purely a physiological or mechanical load-related issue, strictly. Is that a fair statement? We just lost you for a second there, Pete.

SPEAKER_00 23:09

Yeah, I I yeah, I'm back now. Sorry about that. Um yeah, I lost you at catastrophization, I think.

SPEAKER_01 23:17

I was I was just sort of saying that it it it feels like you know we've got some central sensitivity. Um there's we're moving towards, you know, that very broad um and multifactorial approach to treating tendons. Um because there can be yeah, catastrophization, ferovoid, and there can be an immune response. There can be uh lots of different factors which are leading to overloading that tendon, and it's not purely just a mechanical load issue.

SPEAKER_00 23:51

Yeah, yeah, without a doubt. And that's that's that's what I was sort of talking about at the start, where it's just a heterogeneous and heterogeneous patients that we see. And uh we can't expect that they're gonna walk in the door, we're gonna say, Okay, you've got an Achilles Tenopsy, take this program, off you go. I'll see you in two weeks, and and you know, you'll start to see some improvements because it's it's definitely we know now not that simple. And the trials are all showing that because when we look at trials of exercise, it doesn't uh appear to work in a lot of people that we see.

SPEAKER_01 24:29

Yeah so so diving into you've just opened up um about exercise, Pete. And we your internet's just a little bit playing playing up just a fraction, I think, at the moment. But we're we're talking about sort of exercise as a modality of trying to treat the tendon. Um how do you think about exercise now? And we know generally that okay, unless you've got a very reactive tendon, that the complete rest is probably the wrong approach. So how are you now thinking about loading tendons? And there's all sorts of different types of load that you can think about when you're putting um when you're trying to exercise uh a tendon.

SPEAKER_00 25:19

Yeah. So uh it's a very good question. It's a very, very good question. I think um uh loading is uh you can view it as um I I think I I tend to view it as what is the outcome you're trying to achieve. Now we know if you want to make a muscle stronger, you do a certain type of exercise. You generally would do something with a bit of resistance over time. Um, if you want to make a tendon stronger, it's the same thing. You just need to do some resistance over time. Uh so that works that works well, and we know that that works from lots of uh studies. Uh, if you want to make pain better, it's a bit less clear. Uh so there's no such thing as an exercise that is the best exercise for making pain better. Uh it's it's just that there is um movement is positive for people, probably because it improves their confidence, improves their self-efficacy, reduces their movement-related fear, and all of those things are positive for them. So uh so I think I you know the way that I think about it at the moment is that we we sort of use exercise uh expecting to get expecting that there's going to be a relationship between all these mechanical, biomechanical benefits like tendon strength and muscle strength and pain benefits, but actually there isn't. It's just it's just that you're improving the tissues and pain's improving uh at the same time, probably for different mechanisms. So where we're at at the moment is trying to understand if you do an exercise, what why did why does someone improve? Is it because they're you know feeling a bit more confident? Is it because they're uh they've got a bit more metabolic uh health because of those general exercise benefits? Is it because you're targeting the tendon itself? Um that's and and I think you know it understanding that is going back to what we were talking about before, and that is the heterogeneo presentation and trying to target what we think is gonna be the highest value thing for the person there. So if I see an Achilles patient who's got a very high BMI, uh diabetes, metabolic issues, um, and they come to me with, of course, I'm gonna give them a loading program for their Achilles. I saw someone like that uh last week. Um I gave him uh one simple exercise for his Achilles, which is an isometric hold in a plans of grade position, which he found very hard because his body weight is probably about 120 kilos. Um even that was hard for him. But pretty much pretty challenging. Yeah, yeah, yeah. But the key focus for him is uh doing some getting aerobically fit and getting genuine strong.

SPEAKER_01 28:22

Some getting his metabolic health. Yep, yeah, exactly.

SPEAKER_00 28:26

Yeah, that's and that's what yeah, exactly. And that's what we we try and shift the focus away from the tendon to the whole person. Because that's where he's gonna get the most benefit, I think, over time.

SPEAKER_01 28:39

I'd love to sort of break down those two little areas a little bit. You touched on okay, you gave him an isometric exercise. Like there's a big movement in physio that okay, isometric loading can be good for some pain modulation. Um, I I I use isometrics as a pain modulator, but then when I feel like there's an issue with their load capacity and I need to get shit stronger, so to speak, I'll I'll give them some concentric and then maybe some eccentric work ultimately. But isometric stuff does often I think seem to modulate some some some lower limb tendon pathologies. Is that the way that you view it in in how you use it?

SPEAKER_00 29:31

Yeah, look, I think uh so the history of isometrics is that it's been used a lot over time for um various reasons, but it became popular in tendinopathy when Ebony Rio did her uh studies in patel tendon. Now this was 2015, I believe, and at that time there was a very um uh quite a quite a good reduction in pain with an isometric uh for patell tendon. Now that that I think that's true, that probably does happen. What what is not so certain is um uh what is not so certain is um whether isometrics, if you if you give what we know from studies is if you give a bunch of people with tendon pain isometric exercise, they will get uh experience an improvement in their symptoms pretty much straight away. Uh and if you give um another bunch of people with tendon pain uh dynamic exercise like doing a calf raise up and down, they will also experience reduction in pain. And that reduction in pain will be similar. That's what we know now. So it seems to be that just loading is going to bring about loading the tendon. Yeah, is gonna bring about some reduction. But I think where isometrics is is special is that most people will tolerate isometrics from an earlier stage in their pathology or in their problem. Um so if you've got a bunch of people that have got more severe symptoms, they're more likely to tolerate the isometric loading. So I think that's where that's where I think there is some truth to what you're saying, and that is that it can modulate pain uh better, easier, sooner uh with the isometric loading for some people. Uh but my my what we sort of talk about a lot these days is that we can use isometrics for so many different things aside from just pain modulation. Yeah. So in clinical practice, one of the key things that we that I talk about and do is um loading the tendon in specific positions that are gonna achieve a lot of tension and strain, and uh you can do that really well with isometrics because you can put them into whatever position you want and load them heavy. So that so we you know there's two ends of the spectrum. There's using it for pain uh modulation, which is useful, as you say, but it's also then the functional and uh you know getting physical uh adaptations with isometrics as well.

SPEAKER_01 32:10

Yeah. Do you use isometrics as well for the upper limb? Like do you treat a lot of upper limb tendinopathies?

SPEAKER_00 32:21

Yeah, it's a good it's a good question. Uh I I'm pretty um well established and known for Achilles these days. Uh so it's it's just over the years, if you look at the proportion of patients that are Achilles of mine, it's just grown and grown and grown and grown and grown. Um but there are other things that sneak in. I see a lot of patella, I see a lot of hamstring, um, and funnily enough, I do see a bit of um elbow tendinopathy, and I see distal biceps. Okay. So they they they come to me now. I don't see shoulders because I just don't see shoulders, um, but I uh I do see the elbow and I do isometrics with them as well. We do a lot of isometrics with the elbow. So ten, you know, lateral elbow tendon, uh medial elbow tendon, um uh and distal biceps tendon, and it works really well.

SPEAKER_01 33:16

Yeah. Yep. Okay, cool. And have we do you think we've in terms of sort of tendon loading, have we become a bit too obsessed with specific sort of exercise principles or protocols rather than okay, assessing the demands of what they functionally need and then replicating that? Like you like you were saying, okay, you can load uh uh put a hell of a lot of load through a tendon isometrically, you know, with a Smith's machine or loading into you know a Silius, a bent knee sort of calf hold will will load your Achilles in in quite a profound way with you know uh some good heavy heavy weight into it, which is quite challenging for people.

SPEAKER_00 34:10

I think we might have, and I think this goes I would I would answer that by going back to the heterogeneous we're talking about earlier. So um, you know, if you look at those four groups that we talked about, the ones that are very much uh dominated by physical uh loading versus psychological versus systemic versus nosoplastic. Um I if you've got someone who's an athlete who's dominated by loading, then you do need to go to that higher level of load.

SPEAKER_02 34:44

Yep.

SPEAKER_00 34:44

Uh but I absolutely agree if you've got someone who's systemic or psychological, that is that's not necessary. You don't need to do that. And I think we are too obsessed with okay, how's the best way to load load it, or what's the best protocol? It can be very simple and it'll be guided by what they need to do. So almost like a graded exposure type approach would be absolutely fine for that person.

SPEAKER_01 35:11

Yeah, okay. So you see a lot of Achilles and and and quite a few patella tendons. Why do they still seem to function a little bit differently? Even though, you know, in the you you your GTPS or your your your glute tendinopathy or your proximal hamstring tendinopathy, they're all have we've got your SOS signal again trying to trying to switch on the light. Um is it just that their anatomical basis is different, how they're tolerating load is different, so we need to you know, and and and as you've mentioned several times, that you know, all these tendons are heterogeneous. So they behave a little bit differently. So we need a very different rehab approach for each particular low lower limb tendon.

SPEAKER_00 36:13

Yeah, I think I think that's um I think that's right. Because um uh basically if you look at those two tendons that you highlighted, the Achilles and Patella, they're very different to all the other tendons in that they are the highest loading and probably the ones that you would define as the stretch-shortened cycle tendons, the ones that store the most energy. So they are different to all the other ones. So they they will, you know, at some point or at some you know uh some progression of your rehab require that person to take uh more uh loading than maybe some of the other ones that we see. So there's probably that as well, because there's so I mean everyone loads their Achilles. If you look at about if you look at Achilles tendon walking, you're gonna get loads of up to five, six times body weight.

unknown 37:07

Yeah.

SPEAKER_00 37:07

And that's just with walk. And that's just walking. Yeah, that's just walking. So if you've got your 60-year-old who likes to go for a walk when you know, when they go for holidays around Europe and they're walking around, you know, Italy and they're walking up and down hills, they could be exposing their Achilles tendon to six, seven times body weight.

SPEAKER_02 37:25

Yeah.

SPEAKER_00 37:25

Uh so you know, you need to think about that in the in the rehab. Needs to be strong. It does. So there's a requirement for some level of loading for these tendons, uh, possibly more so than some of the other ones that we see.

SPEAKER_01 37:42

Yeah. So moving away from loading of the tendons and onto sort of talking about hormones and sort of metabolic health, there's there's quite a shift now about clinicians being more mindful and opening that conversation with with patients a lot more. Do you feel how strong and how clear is the relationship between poor metabolic health and maybe poor endocrine health and tendinopathy?

SPEAKER_00 38:20

Yeah, so it is fairly strong. We've got a lot, we've got evidence that um uh if someone has an elevated BMI, uh that that is a that there's a strong link with tendinopathy.

SPEAKER_01 38:35

We've also got evidence that can that BMI also exist. Does that mean that they can have an increased risk in tendinopathy in their upper limb as well? So it's not just load related to the lower limb?

SPEAKER_00 38:53

Yep, yep, yep. Exactly right. So so therefore we think it's not just the loading, it's something else, it's something systemic. Uh and then there's also links with directly with dyslipidemia, uh, elevated cholesterol, and tendinopathy as well. So there are there are links that uh indicate that tend and we also see people with familial hypercholesterolemia have uh tendinopathy and fatty deposits in their tendons. Uh so we see we see that you know if you've got circulating lots of circulating cholesterol, then that is going to influence the metabolism of the tendon and uh potentially uh be problematic for for people. So that's that is I mean it's it's it's not known at this point though, uh, you know, how much of a difference targeting that will be in our treatment. So we we don't know that at the moment.

SPEAKER_01 39:53

So Pete, do you put people on GLP1 agonists? Well, maybe you don't prescribe them, but you know, there have been a a huge success for altering people's metabolic health. And a bit of a wonder drug for people's metabolic health and to shift weight, clearly. And do you work or have you seen trends that actually addressing people's metabolic health with something like a GLP one has actually uh really revolutionized people's tendon pain?

SPEAKER_00 40:31

So it's a very it's an interesting question and it's uh it's a complex question because uh there I mean the answer probably on the surface level is yes. They you know it can help people to metabolically get better and get uh lose weights, and that's all very positive. However, there are uh some some issues with the GLP1 uh drugs, and those issues Around muscle mass in particular. Well, yeah, they're they're fairly well documented. Basically, what happens is there's two there's two key issues. One is uh people still, I mean they're losing uh they're losing fat, they're also losing muscle at the same time. That's one issue. If you go off them, therefore, you gain weight again, people rebound and gain weight, and most of the weight they gain is not muscle, it's gonna be it's gonna be fat again. Fat again, yeah. So metabolically they're worse off. So going off them is very problematic. Is very, very problematic for for people. Metabolically, they become worse off. Now, even if you stay on them, uh as with all drugs, they become less effective over time. So you have to increase your dose or you have to uh find other ways. So, I mean, there's one way that they do work, and that is if the person shifts their lifestyle. So they have to be, they have to be um they have to be taken in conjunction with uh real lifestyle change, otherwise they're just they're they're not good at all, uh in my opinion. So uh so we have seen good success and and definitely we do we do uh recommend that patients go and speak to their GP at when they've got um, you know, and you have to meet certain criteria as well. You have to be at a certain level uh of obesity and metabolic health issues to be also candidate for the case.

SPEAKER_01 42:32

Well well these days you can you can buy it online over here pretty pretty easily, but um Oh really?

SPEAKER_00 42:38

Wow. Yeah, yeah, yeah. Interesting, yeah. They are very, very, very popular these days, and you do see a lot of patients that are on them already um nowadays. Yeah.

SPEAKER_01 42:48

Okay, and so does the same exist for hormones, you know, estrogen and testosterone even we know estrogen most tendons are sort of estrogen loving. They're super important sort of hormones to to tendon health, aren't they?

SPEAKER_00 43:07

They are. They are. So um if you if you look at the sort of epidemiology of uh tendon injuries around females, they spike at um at uh around that perimenopause age when they're starting to reduce their estrogen levels. However, one of the things that I uh counsel patients, female patients around, because a lot of female patients will come in their 60s and say, look, I'm postmenopausal, but um the body is pretty amazing in having multiple pathways, and we talked about signaling pathways before to do things like keep tendon healthy and uh you know grow muscle and all the other things. That's what there's multiple pathways there, uh, probably for a reason, and that is some will upregulate and downregulate throughout our lives for. Various reasons. So if you're having uh depletion of estrogen, you're probably going to have other pathways. So we we our general approach uh with the clinical patients that we see in that category is just just do general exercise, general strength training, and that will be enough. You don't need to worry about that depletion of estrogen you know past that menopause age. It's a problem when your body is uh trying to adjust in that in that menopause.

SPEAKER_01 44:31

So you're not necessarily suggesting HRT for tendon pathologies?

SPEAKER_00 44:38

No, we we we we still do in that in we still do if they're having and that all comes down to you know their symptoms and what symptom profile they've got. But if they if they have a lot of symptoms, multi-site symptoms, but also other symptoms, hot flushes, sleeping issues, other problems that they get around that time, then yes, that is we we do recommend it because there's no there's no issues with uh well there's no there's no major there's there's side effects with all drugs, but there's no uh there's not the side effects that we used to think were related to HRT. Yeah.

SPEAKER_01 45:14

And look with HRT, there's a massive um positive impact on their cardiac health and also bone health. Um so the there's yeah, so long as there's no other sort of uh cancer risk factors there. I know we're cutting close for for for time, Pete, but passive treatments. Shockwave, PRP, any other interventions that you like? I know you you know you've recently you were showing an RCT that we're in in Achilles where shockwave just doesn't do anything. Um so do you are you an advocate for shockwave and PRP at times?

SPEAKER_00 45:58

It's an interesting one. It's a very interesting one. Uh we um like so the main the main adjuncts are um all the stuff that we do in a physiotherapy clinic like hands-on work, um heel wedges, uh shockwave, uh but then there's the um things that the docs do, which is all the injections that we have as well. So uh they're the main they're the main things. Uh they uh when you look at all of them, the evidence is not that is is not strong. We we look for basically you've got this needle of evidence, uh not effective, going to effective, and most things are in the middle here where we're not sure, we're uncertain. Uh when we when we go towards not effective, then we start to think, should we really be using it? And that's where shockwave has gone recently with the more high-quality studies that are showing that it's probably not effective. Uh, and we did one of those, but there's not only ours, there's an there's a bunch of them now showing that it's not effective versus placebo. But it's interesting because the shockwave community is very, very, very it's it's like the you know, people are very invested in doing shockwave therapy, and uh it's you know it gets a real response when you tell them that you know maybe this is not working over and above placebo.

SPEAKER_01 47:20

And is that for all tendons, or is that m specifically more the Achilles tendon? I know you were talking about um some of your recent studies. There were Achilles tendons that you were specifically talking about. Yeah.

SPEAKER_00 47:36

So um we our systematic review, which was just published, was in Achilles tendonopathy. We have very good evidence now in uh insertional that it is not different to placebo. Uh in the mid-portion, we also have it's also pointing in that direction, but the evidence is less certain. So um uh the other the other tendons are not as progressed as the Achilles, because that's where most of the research is at the moment. Okay.

SPEAKER_01 48:05

So what are some little nuggets that you know clinicians or patients having tricky sort of tendon pathology? Are there any amazing little tips that you could give that they should be thinking about for optimizing their tendon and getting back to normal function and reducing the pain?

SPEAKER_00 48:29

Well, the probably the most most important one I think is just helping the person understand their problem. And it's all the things that we talked about before, which is understanding what are the key things for them. Is it nosoplastic, is it psychological, is it uh is it uh systemic, or is it just a load condition? Um helping them understand that and then um and then guiding them through those pathways of treatment. Um the other thing is just load them if it load them the loading doesn't need to be complex. It just need you just need to load the tendon and then just give them some general things to do that are functional and um you know relevant for that person. But you know, even if you give them one good loading exercise for the tendon, that is enough.

SPEAKER_01 49:20

Okay. Cool. Pete, I know you've got a dash, you've got a patient to go and see. Um so thank you so much for your time. It's been super fascinating. I've loved chatting to you. We have to get you over, have a coffee um when you're next in London. Um look, I'd love to pick your brain further in in some of these areas because I'd love to dive a bit deeper into sort of the biochemistry of tendon cells and and and that. But it's been super interesting and I'm sure there's a lot of great nuggets for our listeners out there.

SPEAKER_00 49:51

Fantastic. Thanks a lot, Simon. Thanks for having me on. Thank you very much. Excellent. Thanks, Pete.