Talking Tendons

Do psychological, cognitive, and contextual factors influence rehab outcomes in Achilles tendinopathy? Mar 01, 2023

This week I talk about a feasibility cohort study which sought to determine whether a larger cohort study addressing this question would be feasible. Listen to hear some interesting preliminary findings.

Merza, E.Y., Pearson, S.J., Mallows, A.J. and Malliaras, P., 2023. The relationship between psychological, cognitive, and contextual factors and rehabilitation outcomes in Achilles tendinopathy: A prospective feasibility cohort study. Physical Therapy in Sport.
Mallows, A., Jackson, J., Littlewood, C. and Debenham, J., 2020. The association of working alliance, outcome expectation, adherence and self‐efficacy with clinical outcomes for Achilles tendinopathy: A feasibility cohort study (the MAP study). Musculoskeletal Care, 18(2), pp.169-176.

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Does high load and high strain exercise have any benefit for Achilles tendinopathy? Feb 21, 2023

We have known for a while that type of exercise intervention (e.g. intensity, frequency, etc) does not seem to influence self-reported outcomes such as pain. Maybe all the benefits from exercise are explained by non-specific effects, or maybe exercise has benefits that do not depend on the type of exercise.

In this episode, I discuss 3 studies that look into (at least partly) other benefits that we may see at the level of the muscle and tendon from higher-load exercise interventions.

References:

Radovanović, G., Kunz, J., Bohm, S., Arampatzis, A. and Legerlotz, K., 2021. Reliable and effective novel home-based training set-up for application of an evidence-based high-loading stimulus to improve triceps surae function. Journal of Sports Sciences, 39(24), pp.2786-2795.

Radovanović, G., Bohm, S., Peper, K.K., Arampatzis, A. and Legerlotz, K., 2022. Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial. Sports Medicine-Open, 8(1), pp.1-19.

Radovanović, G., Bohm, S., Arampatzis, A. and Legerlotz, K., 2023. In Achilles Tendinopathy the Symptomatic Tendon Differs from the Asymptomatic Tendon While Exercise Therapy Has Little Effect on Asymmetries—An Ancillary Analysis of Data from a Controlled Clinical Trial. Journal of Clinical Medicine, 12(3),

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Proximal Hamstring Tendinopathy - the forgotten tendinopathy Feb 15, 2023

This week, I had an engaging conversation with Anthony Nasser, an up-and-coming researcher on tendinopathy who recently completed his PhD on proximal hamstring tendinopathy. Our discussion covered the reasons for the lack of research attention towards this condition, the current state of evidence, and insights from his doctoral studies. You can find the full conversation here.
Here are Anthony's related publications:

Nasser, A.M., Pizzari, T., Grimaldi, A., Vicenzino, B., Rio, E. and Semciw, A.I., 2021. Proximal hamstring tendinopathy; expert physiotherapists’ perspectives on diagnosis, management and prevention. Physical Therapy in Sport, 48, pp.67-75.

Nasser, A.M., Vicenzino, B., Grimaldi, A., Anderson, J. and Semciw, A.I., 2021. Proximal hamstring tendinopathy: a systematic review of interventions. International journal of sports physical therapy, 16(2), p.288.

Nasser, A., Semciw, A., Grimaldi, A., Rio, E., Pizzari, T. and Vicenzino, B., 2022. Core outcome set development for proximal hamstring tendinopathy (COS-PHT): a study protocol. Physical Therapy Reviews, 27(4), pp.313-319.

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How useful is palpation for diagnosis and assessment? Feb 07, 2023

Palpation can be useful for the diagnosis and assessment of tendinopathy, but there are limits. This is because non-painful tendons can be tender, and tenderness in painful tendons seems to be very slow to get better.

Link to Evidence for Improvement in Local but not Diffuse Pressure Pain Thresholds Following Physical Therapist Interventions for Tendinopathy: A Systematic Review

Link to Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players

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Muscle and tendon tuning and implications for tendon rehabilitation Jan 31, 2023

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

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Achilles forces during common rehab exercises and habitual activities. Jan 25, 2023

This talking tendons episode will discuss a study by Igor Sancho, PhD, assessing Achilles forces during common rehab exercises and habitual activities and how this relates to reported pain among runners. Some interesting implications for practice.

Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory study

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Graded exposure in tendinopathy rehabilitation. Dec 12, 2022

In this episode, I am discussing kinesiophobia in the context of tendon rehab and how rehab can be conceptualised as graded exposure for some people.

References

1) Physiotherapy management of Achilles tendinopathy

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Load test pain and kinesiophobia and how they interact in tendinopathy assessment Dec 08, 2022

In this episode, I talk about load test pain assessment and how this can also be used to assess kinesiophobia and movement apprehension.

References

1) Physiotherapy management of Achilles tendinopathy: https://pubmed.ncbi.nlm.nih.gov/36274038/

2) Kinesiophobia Severity Categories and Clinically Meaningful Symptom Change in Persons With Achilles Tendinopathy in a Cross-Sectional Study: Implications for Assessment and Willingness to Exercise: https://pubmed.ncbi.nlm.nih.gov/35295417/

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Functional impairments persist in Achilles tendinopathy when people are returning to running Jul 25, 2022

This is an interesting study from the Delaware tendinopathy group among others investigating a host of structural, tissue property, functional and pain factors that may persist among people with Achilles tendinopathy making a return to running. Provides guidance to clinicians about potential impairments to consider assessing.

Here's the link to the study:

Corrigan, P., Hornsby, S., Pohlig, R.T., Willy, R.W., Cortes, D.H. and Silbernagel, K.G., 2022. Tendon loading in runners with Achilles tendinopathy: Relations to pain, structure, and function during return‐to‐sport. Scandinavian Journal of Medicine & Science in Sports.

Here's the link to my upcoming course series in the UK in Sept:

https://www.eventbrite.com/cc/mastering-lower-limb-tendinopathy-uk-sept-2022-670009

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Understanding the patient perspective in Achilles tendinopathy Jul 19, 2022

In this episode I talk about three qualitative studies that aim to understand the patient perspective and patient motivations in Achilles tendinopathy. I find this work really helps clinicians to understand what patients are gong through so we are able to be empathic and help them. Hope you enjoy!

Here's a link to courses in the UK:

https://www.eventbrite.com/cc/mastering-lower-limb-tendinopathy-uk-sept-2022-670009

Here are the studies:

Turner, J., Malliaras, P., Goulis, J. and Mc Auliffe, S., 2020. “It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away.” A qualitative study exploring individuals’ beliefs and experiences of Achilles tendinopathy. PloS one, 15(5), p.e0233459.

Mc Auliffe, S., Synott, A., Casey, H., Mc Creesh, K., Purtill, H. and O'Sullivan, K., 2017. Beyond the tendon: experiences and perceptions of people with persistent Achilles tendinopathy. Musculoskeletal Science and Practice, 29, pp.108-114.

Mallows, A., Head, J., Goom, T., Malliaras, P., O'Neill, S. and Smith, B., 2021. Patient perspectives on participation in exercise-based rehabilitation for Achilles tendinopathy: A qualitative study. Musculoskeletal Science and Practice, 56, p.102450.

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Humans are lazy (or efficient!) hoppers: the importance of instructions in submaximal human hopping Jul 16, 2022

This paper is more than 30 years old but it is a beauty. Farley et al talk about human preferred hopping frequency and how it relates to metabolic cost and how fast muscles are contracting, and also how our instructions can influence how well people hop (and the mechanisms that drive this). Important to consider hopping instruction when assessing submaximal hopping in the clinic.

Here's a link to the paper

Farley, C.T., Blickhan, R., Saito, J. and Taylor, C.R., 1991. Hopping frequency in humans: a test of how springs set stride frequency in bouncing gaits. Journal of applied physiology, 71(6), pp.2127-2132.

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Steroid injection for Achilles tendinopathy? Jul 15, 2022

There is so much debate about the use of steroids for tendinopathy. Opinions vary between 'you should never use steroid as will lead to recurrence, worse pain or rupture' to 'it's fine, do as much steroid as you like'. Opinions dominate as we have limited data. Until now. This is the first trial looking at 2 year outcome for exercise +/- steroid for Achilles tendinopathy. Interesting findings!

Here's the link to the study:

Johannsen, F., Olesen, J.L., Øhlenschläger, T.F., Lundgaard-Nielsen, M., Cullum, C.K., Jakobsen, A.S., Rathleff, M.S., Magnusson, P.S. and Kjær, M., 2022. Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy: A Randomized Clinical Trial. JAMA Network Open, 5(7), pp.e2219661-e2219661.

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Does pain science education improve outcomes for Achilles tendinopathy? Jun 28, 2022

This is a new and lovely to read randomised trial comparing pain science education (including lots of good biopsychosocial info) versus placebo education for Achilles tendinopathy. Some interesting findings and potential avenues for further study. Definitely worth a listen and read.

Here is a link to the actual paper:

https://journals.lww.com/pain/Abstract/9900/The_effects_of_pain_science_education_plus.122.aspx

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Strength and other impairments in runners with Achilles tendinopathy Jun 15, 2022

This is a new study from my PhD student, Igor Sancho. He looks at strength, psychological and other factors that may be different between health runners and runners with Achilles tendinopathy. Seated calf raise 6RM seems to be the strongest predictor of having Achilles tendinopathy. Some interesting other findings and clinical implications.

Here is a link to this paper, and Igor's other PhD papers:

Sancho, I., Morrissey, D., Willy, R.W., Tayfur, A., Lascurain-Aguirrebeña, I., Barton, C. and Malliaras, P., 2022. Recreational runners with Achilles tendinopathy have clinically detectable impairments: A case-control study. Physical Therapy in Sport, 55, pp.241-247.
Sancho, I., Malliaras, P., Barton, C., Willy, R.W. and Morrissey, D., 2019. Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis. Gait & posture, 73, pp.189-201.
Sancho, I., Morrissey, D., Willy, R.W., Barton, C. and Malliaras, P., 2019. Education and exercise supplemented by a pain-guided hopping intervention for male recreational runners with midportion Achilles tendinopathy: a single cohort feasibility study. Physical Therapy in Sport, 40, pp.107-116.

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Exciting new insights into tendon adaptation with load May 26, 2022

On this episode I focus on a new study from my PhD student Eman Merza. It is a cross-over randomised trial testing the effect of high and low contraction time and high and low intensity isometric contractions on acute changes to tendon volume and stiffness. Some very interesting potential insights for tendon adaptation. Good work, Eman!

Hope you enjoy.

Peter

Here is a link to the study (open access for a few weeks):

https://journals.biologists.com/jeb/article/225/10/jeb243741/275395

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Achilles tendinopathy clinical and patient subgroups May 05, 2022

Had a lovely chat with Shawn Hanlon who is a PhD candidate about his relatively new paper exploring patient features and clinical characteristics and how they may define certain subgroups of Achilles tendinopathy . Lots more to learn in this field and this is early work, but we discuss some of the juicy potential clinical implications.

Hope you enjoy!

And here is the link to the paper and also the

1/ Hanlon, S.L., Pohlig, R.T. and Silbernagel, K.G., 2021. Beyond the diagnosis: Using patient characteristics and domains of tendon health to identify latent subgroups of Achilles tendinopathy. journal of orthopaedic & sports physical therapy, 51(9), pp.440-448.

2/ And this is the bumper issue of JOSPT from 2015 that is all about tendinopathy: journal of orthopaedic & sports physical therapy, 45(11)

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Central pain processing and Achilles tendinopathy Apr 23, 2022

There is lots of debate about the pain mechanisms, particularly if there are central changes, in Achilles and other tendinopathies. Most studies in the literature use proxy measures of central sensitisation like pressure pain threshold away from the painful site, Other measures like conditioned pain modulation have been investigated less frequently. In this episode of talking tendons I discuss a huge new study investigating CPM in Achilles tendinopathy with some interesting findings and implications.

Hope you enjoy!

Here is the link to the study:

Mkumbuzi, N.S., Mafu, T.S., September, A.V., Posthumus, M. and Collins, M., 2021. Conditioned pain modulation is not altered in recreational athletes with Achilles tendinopathy. Translational Sports Medicine, 4(1), pp.147-153.

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The amazing benefits of biologic springs like the Achilles tendon Apr 20, 2022

This is one of my favourite narrative expert reviews that discusses the benefits of human biologic springs like the Achilles tendon. These benefits can be summarised as follows:

Metabolic energy conservation
Amplification of muscle power output
Attenuation of muscle power input

Some really interesting mechanisms and insights for rehabilitation . I hope you enjoy!

Here is the link to the study:

Roberts, T.J. and Azizi, E., 2011. Flexible mechanisms: the diverse roles of biological springs in vertebrate movement. Journal of experimental biology, 214(3), pp.353-361.

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Gluteal tendinopathy chat with Chris Clifford Apr 18, 2022

I had a great time talking Gluteal tendinopathy with Chris Clifford. Chris is an experienced clinician from Glasgow who is in the throws of completing his PhD on this condition. We chatted about rehab, the use of isometrics, difficult patient groups and how to navigate them, and much more.

I hope you enjoy!

Here is 2 related publications from Chris' PhD:

1/ Clifford, C., Paul, L., Syme, G. and Millar, N.L., 2019. Isometric versus isotonic exercise for greater trochanteric pain syndrome: a randomised controlled pilot study. BMJ open sport & exercise medicine, 5(1), p.e000558.

2/ Clifford, C., Challoumas, D., Paul, L., Syme, G. and Millar, N.L., 2020. Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ open sport & exercise medicine, 6(1), p.e000760.

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Do dietary supplements improve outcomes in tendinopathy? Apr 11, 2022

Patients often ask about dietary supplements and if they may be helpful in recovering from a tendinopathy problem. There is a new systematic review out which has attempted to answer this question and it is the subject of this episode of talking tendons.

I hope you enjoy.

Here is the reference

Qiu, F., Li, J. and Legerlotz, K., 2022. Does Additional Dietary Supplementation Improve Physiotherapeutic Treatment Outcome in Tendinopathy? A Systematic Review and Meta-Analysis. Journal of clinical medicine, 11(6), p.1666.

And links to upcoming Mastering Lower Limb Tendinopathy course in Australia

https://www.eventbrite.com/cc/mastering-lower-limb-tendinopathy-live-australia-211689

See omnystudio.com/listener for privacy information.

Is wait and see a viable option for Achilles tendinopathy? Apr 09, 2022

Will midportion Achilles pain improve if you wait and see? This is often a really important question to discuss with patients. Luckily we have some evidence to answer it which I explore in this short podcast (9 minutes). Hope you enjoy.

Here are the related studies

1/ Horstmann, T., Jud, H.M., Fröhlich, V., Mündermann, A. and Grau, S., 2013. Whole-body vibration versus eccentric training or a wait-and-see approach for chronic Achilles tendinopathy: a randomized clinical trial. journal of orthopaedic & sports physical therapy, 43(11), pp.794-803.

2/ Rompe, J.D., Nafe, B., Furia, J.P. and Maffulli, N., 2007. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. The American journal of sports medicine, 35(3), pp.374-383.

3/ de Vos, R.J., van der Vlist, A.C., Zwerver, J., Meuffels, D.E., Smithuis, F., van Ingen, R., van der Giesen, F., Visser, E., Balemans, A., Pols, M. and Veen, N., 2021. Dutch multidisciplinary guideline on Achilles tendinopathy. British journal of sports medicine, 55(20), pp.1125-1134.

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Education interventions in rotator cuff tendinopathy Mar 09, 2022

We all understand providing education for people with rotator cuff tendinopathy (and other conditions) is really important but we have very few resources or guidance regarding what should be delivered and how. In this episode I discuss two qualitative studies exploring the views of patients and expert clinicians about what needs to be included in education for rotator cuff tendinopathy. We the findings to develop an education resource which is embedded in one of the papers (Cridland et al). Some interesting insights - I hope you enjoy.

Here are links to the papers:

White, J., Mc Auliffe, S., Jepson, M., Burstein, F., Hopman, R., Morrissey, D., Haines, T. and Malliaras, P., 2020. ‘There is a very distinct need for education’among people with rotator cuff tendinopathy: An exploration of health professionals' attitudes. Musculoskeletal Science and Practice, 45, p.102103.

https://pubmed.ncbi.nlm.nih.gov/32056827/

Cridland, K., Pritchard, S., Rathi, S. and Malliaras, P., 2021. ‘He explains it in a way that I have confidence he knows what he is doing’: A qualitative study of patients' experiences and perspectives of rotator‐cuff‐related shoulder pain education. Musculoskeletal Care, 19(2), pp.217-231.Vancouver

https://pubmed.ncbi.nlm.nih.gov/33258225/

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Chat with Ruth Chimenti: 'the best exercise is the one your patient will do' Feb 21, 2022

Here is my recent chat with Dr Ruth Chimenti about Achilles tendinopathy

We touched on some interesting topics, including

Kinesiophobia and whether it changes with treatment
Pain education for tendinopathy - what should it involve? does it work?
Patient centred rehabilitation

Here is a link to some brand new trial data from Ruth's lab - she tested efficacy of pain education which is novel for Achilles tendinopathy.

https://clinicaltrials.gov/ct2/show/study/NCT04059146

And here is a link to the protocol paper:

https://pubmed.ncbi.nlm.nih.gov/33141102/

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Chat with Colin Griffin: top tips about assessment and management for Achilles tendinopathy Feb 06, 2022

Enjoyable chat with Colin Griffin who is undertaking an exercise trial for Achilles tendinopathy. We touched on so many important rehab considerations, including:

Strength profiling for Achilles tendinopathy
Assessing endurance, maximal dynamic and isometric calf capacity, and plyometric function and reactivity
Home vs gym based rehab
Why some people may have poorer outcomes

Here is a link to his open access trial protocol: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-021-04553-6

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Systematic review on plantarflexor muscle impairments in Achilles tendinopathy. Jun 15, 2021

In this episode I talk about a new systematic review on plantarflexor muscle impairments in Achilles tendinopathy. It is clear that the relationship is not as clear as what you might think, and there are also some very interesting insights to how plantarflexor dysfunctions may change following rehabilitation.

Link to paper

Are Plantarflexor Muscle Impairments Present Among Individuals with Achilles Tendinopathy and Do They Change with Exercise? A Systematic Review with Meta-analysis

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New Exercise Evidence for Patellar Tendinopathy Dec 05, 2020

This high quality trial provides further evidence to shift us away from eccentric training for Patelar Tendinoapthy.

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Investigating pressure massage vs eccentric exercise in Achilles tendinopathy. Apr 13, 2020

In this episode I talk about a relatively new trial investigating pressure massage versus eccentric exercise for Achilles tendinopathy in a randomised trial. I hope you enjoy!

Also, if you have some time on your hands during this time of isolation and need to catch up on CPD head on over to www.tendinoapthyrehab.com. I am offering my online Mastering Lower Limb Tendinopathy course for $295.

See omnystudio.com/listener for privacy information.

Isometric exercise and their effect on tendon pain Nov 20, 2019

Hi All,

On this talking tendons episode, I dive into the very murky world of isometric exercise and their effect on tendon pain. A new study by Sinead Holden and team brings some (just a little) light to the evidence. I argue that isometrics are useful for managing tendinopathy, but using them for short term pain reduction is just the tip of the iceberg.

Also if you're wanting to earn some extra CPD before Christmas check out my two upcoming workshops in December in Sydney and Melbourne (bookings).

See omnystudio.com/listener for privacy information.

Interview with Igor Sancho - Feasability of jumping and hopping as rehabilitation for Achilles tendinopathy. Nov 02, 2019

Hi All,

In this episode of Talking Tendons I have an enjoyable chat with PhD student and Spanish physio, Igor Sancho. He has recently published a study that assessed the feasibility of using jumping and hopping as rehabilitation for people with Achilles tendinopathy. We discuss the study and how to apply these findings in clinic.

See omnystudio.com/listener for privacy information.

Isometrics in Tendinopathy: they are useful but they are not the cure for cancer May 21, 2019

Isometric exercise for tendinopathy has exploded onto the scene over the last few years. Unfortunately, the certainty of evidence surrounding their use is far less certain and compelling than what we are told about them but some people. They may work, but the reality is we don't fully understand how and for whom. This episode delves into this uncertainty and provides lots of top tips for how to use isometrics and when they are useful. Enjoy!

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Injection Therapy - What does the evidence tell us? Apr 10, 2019

Despite our best intentions, not everyone with tendinopathy will respond to conservative treatments. Clinicians need alternative options like injection therapy. Injections such as steroid and platelet-rich plasma continue to be popular for tendinopathy, and there are other emerging injections such as the high-volume injection.

Injection TherapyIn Tendinopathy: Art & Science - 4th May 2019 MELBOURNE

booking via link below:

https://www.eventbrite.com.au/e/injection-therapy-in-tendinopathy-art-and-science-tickets-57953819434

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Something IS happening in the tendon! Collagen turnover in people with Achilles tendinopathy Mar 04, 2019

Understanding how tendon recovers from injury and adapts to load is so important and has huge implications on how we manage tendons and the education and advice that we provide patients. This podcast features a relatively new study providing insights into the collagen turnover in healthy tendons and those with tendinopathy, adding critical knowledge to what we know about tendon collagen adaptation over time.

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Isometric exercise for tendinopathy - Variation between humans does exist! Nov 26, 2018

In this week's podcast, I delve into the minefield that is isometric exercise. Is it the best thing since sliced bread? Does everyone respond? What are the key questions we need to understand?

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Does your psychological wellbeing affect your tendinopathy treatment outcome? Oct 08, 2018

In this podcast we consider some new research exploring psychological factors and tendinopathy. There is emerging evidence that, as per other musculoskeletal conditions and as you would expect, they do play a role. I discuss which ones appear to be most strongly linked with tendinopathies.

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Finally some quality exercise research for the management of gluteal tendinopathy! Jun 03, 2018

Hi all, this episode we focus on two recent randomised controlled trials evaluating education and exercise interventions for gluteal tendinopathy, One of them is the best RCT I have read in ages. Well worth a look at their methods, findings and exercise interventions. Hope you enjoy!

See omnystudio.com/listener for privacy information.

Some cool new technology focused systematic reviews that will change our practice May 08, 2018

This episode we focus on technology use in rehab. I'm inspired by the patient will see you now by Dr Eric Topol which I recently read so this weeks podcast covers 2 technology focused systematic reviews. The first is on the efficacy of exergames for treating musculoskeletal pain, and the second is on basically the use of accelerometers and other wearable sensors to monitor rehab exercises. An exciting area that is set to grow hugely and will be part of all of our practices soon.

References to include at the bottom of the podcast and blog:

O’Reilly M, Caulfield B, Ward T, Johnston W, Doherty C. Wearable Inertial Sensor Systems for Lower Limb Exercise Detection and Evaluation: A Systematic Review. Sports Medicine. 2018;1-26.

Collado‐Mateo D, Merellano‐Navarro E, Olivares PR, García‐Rubio J, Gusi N. Effect of exergames on musculoskeletal pain: A systematic review and meta‐analysis. Scandinavian journal of medicine & science in sports. 2018;28:760-771.

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Non-uniform Achilles tendon strain: what is it and should we care? Apr 02, 2018

Hi all

This week on Talking Tendons we discuss Non-uniform Achilles tendon strain and displacement and tackle the important questions…what is it? And should we care?

The paper is by Prof Finni from Finland supported by an international team. This is an exciting space that has already and will continue to improve our understanding of tendon function and ultimately our ability to prevent and manage these injuries.

Hope you enjoy.

Subscribe to the podcast to get the latest episodes.

Join the tendinopathyrehab website for exclusive resources and blog posts, and access to the Mastering Lower Limb Tendinopathy course.

See you next time

Peter

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Efficacy of PRP injections for tendinopathy...really? Mar 07, 2018

This episode I discuss a recent systematic review that concluded that PRP is more efficacious than control injections for tendinopathy, but the plot thickens when we scratch the surface a little.

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