Tendinopathy  playlist

Physio

It is currently widely accepted among clinicians that chronic tendinopathy is caused by a degenerative process devoid of inflammation. The evidence for non-inflammatory degenerative processes alone as the cause of tendinopathy is surprisingly weak. 

In this podcast, Jon Rees a rheumatologist at Cambridge University Hospitals NHS Foundation Trust tells Jill Cook why the role of inflammation offers potential opportunities in treating chronic tendinopathies and should be explored further.

Read the article online: http://bjsm.bmj.com/content/early/2013/03/08/bjsports-2012-091957.full

Time to revisit inflammation in tendons, with Jon Rees

Here’s the podcast that over 12,000 listeners have been demanding – physiotherapist Adam Meakins (@TheSportsPhysio)on a number of controversial topics, including:
Is diagnostic palpation accurate?
Can the sacroiliac joint really be ‘unstable’?
How does ‘touch’ in physiotherapy have its therapeutic effect? 

Adam provides great value on Twitter and on his blog – here you can listen to him in your favourite podcast setting. 

Adam shares his way of explaining neural pain to patients and that alone is worth the price. 

He also discusses his popular blogs on ‘5 Least Favourite Shoulder Rehab Exercises’ as well as ‘Top 5 Shoulder Rehab Exercises’. 

He argues that the key to managing some knee conditions is to manage load and he refers to Scott Dye’s classic ‘envelope of function’ concept. 

And we close by discussing a couple of  figures that have gained great traction in the Twittersphere. You might find them useful in your clinical practice. But it’s a risk on radio – I get that! Enjoy and comment via @BJSM_BMJ or on Facebook.

See also:

Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain: http://bjsm.bmj.com/content/47/17/1095.full

Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis: http://bjsm.bmj.com/content/48/16/1216.full

Rehabilitation for shoulder instability: http://bjsm.bmj.com/content/44/5/333.full

Biomechanics laboratory-based prediction algorithm to identify female athletes with high knee loads that increase risk of ACL injury: http://bjsm.bmj.com/content/45/4/245.full

Adam Meakins' practical physio tips – explaining neural pain, shoulder rehab and managing knee load

What causes tendon breakdown? What are the stages of tendinopathy, and how do they effect your treatment? Is treatment just about eccentric training? When should NSAID’s be used?

This is part of the great discussion I had with Jill Cook about tendons and tendinopathy. We also chatted about some other aspects of tendinopathy, including

Factors that contribute to tendinopathy beyond biomechanics
Eccentrics – what is the future of training to rebuild tendons
Return to sport or running after tendinopathy
Avoiding tendinopathy
Treatment at each stage of tendinopathy
Rehabing achilles tendinopathy
Rehab for hamstring tendinopathy
plus we related all of these to clinical scenarios. Enjoy!

PE #005  Tendons And Tendinopathy With Jill Cook

In her first podcast since being recruited to the La Trobe University Centre for Sports and Exercise Medicine Research (Australia), Professor Jill Cook explains: (i) how tendons break down, (ii) how to assess painful tendons, (iii) how to manage tendon pain DURING a season, and (iv) how to rehabilitate a tendon properly after a season has finished. 

She explains what  a ‘reactive’ tendon is and what a ‘degenerative’ tendon is as well as what sort of loads should be prescribed for patients who have tendon with these pathologies. 

A practical masterclass. Even if you have heard Jill speak before, there will be something new for you here.  Sneak peek – Part 2 focuses on the concept of ‘capacity’ and why it’s an important concept. 

Further reading
Classic paper: Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy
http://bjsm.bmj.com/content/43/6/409.abstract


Professor Jill Cook (La Trobe University) revisits BJSM podcasts after two years: First of Two

In this 2nd of 2 podcasts for 2015 (link to previous one here http://ow.ly/V8h97) Professor Jill Cook from the La Trobe University Centre for Sports and Exercise Medicine Research (Australia) introduces the term ‘capacity’ for physical therapy / physiotherapy. 

‘Capacity’ is a very practical concept that underpins successful tendon rehabilitation. Prof. Cook discusses how to use the figure from the linked paper to list exercises a patient should do. Practical stuff. 13 minutes of gold! 

Timeline:  
1:00m - Why do we need the term ‘capacity’ in clinical practice?

1:30m - Definition – What is tissue ‘capacity’? 

2:15m - The difference between ‘capacity’ and ‘function’ – capacity is tissue-specific

3:15m - Practical example: Hamstring muscle strain 

5:30m - How to use this in the clinical setting – sitting with a patient and explaining the rehab programme 

7:00m - The ‘Capacity’ figure – how to use it with patients to get buy-in to their rehabilitation 

8:30m - ‘Building a bridge’ from what patients can do now to what they want to return to

9:00m - Practical tips including examples of (i) strength, (ii) energy storage, (iii) energy storage & release exercises

12:00m - Summary (30 seconds!)  

Previous podcast: 
How tendons fail, how to treat in season/out of season http://ow.ly/V8h97

Related papers:
The Continuum model of tendinopathy http://ow.ly/V8hLr

The challenge of managing tendinopathy during the season http://ow.ly/V8oTl

Capacity – the paper (with Figure!) that underpins this podcast! http://bmj.co/1MIaBrx

What is tissue ‘capacity’? How does it help successful rehabilitation? Prof Jill Cook (2nd of 2)

Damian Griffin is the Professor of Trauma and Orthopaedic Surgery at the University of Warwick. He trained in Cambridge, Oxford and the United States, and worked as a Consultant in Oxford before taking up the Foundation Chair in Warwick and helping to establish Warwick Medical School.

Damian’s passion is the diagnosis and treatment of hip and groin pain in young adults.  His clinical practice and research are all around joint-preserving surgery for early arthritis, hip arthroscopy, the management of femoroacetabular impingement and sport injuries of the hip. He runs the largest national referral service for young and active people with hip pain in the UK, based at the University Hospital of Coventry and Warwickshire NHS Trust, and for private patients and elite athletes at the BMI Meriden Hospital.

Damian leads a research team based at the University of Warwick, with a portfolio of hip research. In particular he is the chief investigator for the FASHioN trial, a large, multicenter randomised controlled trial of treatments for people with FAI syndrome, comparing surgery with physiotherapy-led rehabilitation: http://www.nets.nihr.ac.uk/projects/hta/1310302

You can follow him on Twitter @DamianGriffin and @warwickOrtho or reach him on damian.griffin@warwick.ac.uk, at www.hiparthroscopyclinic.co.uk or +44 1926 403529. BJSM is grateful for his contribution as a Senior Associate Editor. 

In this podcast, Damian speaks about Sports Hip 2016, a two day international conference held at St George’s park, the home of English football.  The link to conference details:
http://www2.warwick.ac.uk/fac/med/research/csri/orthopaedics/sportsurgery/hip/

Podcast timeline:
0.30 - St George’s Park and the England Football Association Perform Rehabilitation Centre
1.02 - Introduction to Sports Hip 2016: First time for a multidisciplinary meeting on sports hip injuries
1.58 - Instability of the hip
2.47 - Treatment of acute subluxation or dislocation, returning to 
3.23 - Deep gluteal space, piriformis syndrome and sciatic nerve entrapment
4.54 - Cartilage repair
6.04 – Workshops in hip arthroscopy, hip replacement techniques suitable for athletes
6.00 - Workshop in hip arthroscopy
6.57 - New techniques in hip replacement suitable for young active people and athletes.
7.24 - World class rehabilitation after hip surgery
7.50 - Round table on challenges in managing elite athletes
8.15 - Femoroacetabular impingement (FAI) syndrome, and the movement towards reaching a consensus statement.
11.00 - Consensus meeting on FAI syndrome


A deep dive into hip pain. Professor Damian Griffin makes the complicated clear. (Part 1 of 2)

Often tendinopathy will be resistant to even the best traditional rehabilitation methods. Liam West chats to Dr Ebonie Rio, a PostDoctoral Fellow at La Trobe University’s Sports and Exercise Medicine Research Centre in Melbourne. Dr Rio’s research aims to explain the role of the primary motor cortex in tendinopathy. She discusses tendon neuroplastic training (TNT) and how it might help your tendinopathy patients regain pain free function in the clinic.

Timeline
0.40 – Why traditional rehabilitation for tendinopathy might be unsuccessful
1.40 - Changes in primary motor cortex and motor control in tendinopathy
2.35 – What is TNT & how to utilise it?
5.30 – How long does it take for TNT to help patients?
6.30 – Cross education for tendinopathy

Further Reading
Tendon neuroplastic training: changing the way we think about tendon rehabilitation – OPEN ACCESS - http://bit.ly/29ergE3 

Revisiting the continuum model of tendon pathology - http://bit.ly/29rSDPK 


Related Podcasts
Prof Jill Cook revisits Tendon Pathology - http://bit.ly/1UR3tvL 

Prof Michael Kjaer on the pathogenesis of tendinopathy and tendon healing - http://bit.ly/29pOZol 

Defining tissue capacity - http://bit.ly/29iVSKc 



Could TNT blast a hole in treatment barriers in tendinopathy? Ebonie Rio discusses

ACL injuries are some of the most common and debilitating injuries in athletes. In this podcast, Tim Hewett and Kate Webster talk about the biomechanical risk factors for ACL injury, the role and potential of screening, and the use of ACL prevention programmes. 

Tim Hewett is an expert in biomedical engineering work at the Mayo Clinic and Kate Webster is an associate professor at La Trobe University. They are both speaking at the upcoming Sports Medicine Australia Conference-more details can be found here-http://tinyurl.com/h4ndfy2 

Timeline:
0.40 - What is the biggest risk factor for ACL injury?
2.10 - How are ACL injuries preventable?
4.10 - Can we screen for injury risk?
6.00 - Key criteria for RTS.
9:40 - The high risk of re-injury following ACL damage.
13.00 - Are we returning athletes too soon post injury?
     


What predicts ACL rupture? What prevents it? Tim Hewett (Mayo Clinic) and Kate Webster (La Trobe)

Professor Damian Griffin talks about the Warwick Agreement, an international consensus on the management of femoroacetabular impingement syndrome. This podcast brings you right up to date on the most current thinking about hip impingement or FAI.

0.38 Aim of the consensus
1.36 Consensus methodology
2.26 What is FAI syndrome? Symptoms, clinical signs, and imaging findings.
3.40 How should FAI syndrome be diagnosed?
6.26 What is the appropriate treatment for FAI syndrome?
8.26 What is the prognosis of FAI syndrome?
10.23 How should someone with an asymptomatic hip, with cam or pincer morphology, be managed?
11.53 What research is now needed?
14.15 How is this new definition of FAI syndrome going to influence clinical care?

@DamianGriffin #WarwickAgreement

Damian Griffin is the Professor of Trauma and Orthopaedic Surgery at the University of Warwick. He trained in Cambridge, Oxford and the United States, and worked as a Consultant in Oxford before taking up the Foundation Chair in Warwick and helping to establish Warwick Medical School.

Damian’s passion is the diagnosis and treatment of hip and groin pain in young adults. His clinical practice and research focus on joint-preserving surgery for early arthritis, hip arthroscopy, the management of femoroacetabular impingement and sport injuries of the hip. He runs the largest national referral service for young and active people with hip pain in the UK, based at the University Hospital of Coventry and Warwickshire NHS Trust, and for private patients and elite athletes in London and Coventry (www.hiparthroscopyclinic.co.uk).

Damian leads a research team based at the University of Warwick, with a portfolio of hip research. In particular he is the chief investigator for the FASHioN trial, a large, multicenter randomised controlled trial of treatments for people with FAI syndrome, comparing surgery with physiotherapy-led rehabilitation:www.nets.nihr.ac.uk/projects/hta/1310302

You can follow Damian on Twitter @DamianGriffin and @WarwickOrtho or reach him on damian.griffin@warwick.ac.uk



The Warwick Agreement on the management of femoroacetabular impingement syndrome with Damian Griffin

A world leader in sportsphysiotherapy, Associate Professor Dr Kristian Thorborg is from Copenhagen University. He is renowned for his studies and clinical workshops related to patients with hip, groin, hamstring and knee related injuries.

Here he outlines:

- the paradigm shift for the use of exercise to treat conditions such as tendinopathy and hamstring strains. He addresses questions such as ‘What is the ideal type of exercise?’ and ‘Does the body know if the exercise is concentric or eccentric?’

- cheap technology that can be used to help patients measure the load they are using and to check compliance

- the challenge of treating patients in season

- the concept of progression and the different stage of rehab that is preparation for ‘return to play’

- prevention – it needs monitoring of the players – waiting until they show up with pain is too late

Sports physiotherapist Dr Kristian Thorborg drills down on optimal loading. Heavy and Slow!

Eamonn is a wonderful clinician-scientist who graduated with a 1st Class Honours Degree from the University College Dublin (UCD) School of Physiotherapy in 2003 placing first in his class. Eamonn received a prestigious Irish Research Council for Science Engineering and Technology (IRCSET) post-graduate research scholarship. He was awarded his PhD from the UCD School of Physiotherapy and Performance Science in 2006, In this podcast that combines science with clinical application topics include:

• The high prevalence of ankle injuries and the high risk of the development of chronic residual symptoms. 
• The characteristic features of CAI.
• How to manage the young soccer player who sustains an ankle injury.
• Detailed discussion of (1) modified Ottawa Ankle Rules; (2) determination of lateral ligament laxity; (3) syndesmosis assessment.
• How to assess for chronic ankle instability  
• Mechanical insufficiencies including: (1) pathological laxity; (2) arthrokinematic restrictions; (3) synovial changes; (4) degenerative changes.
• Functional insufficiencies including: (1) impaired proprioception; (2) impaired neuromuscular control; (3) impaired postural control/postural balance; (4) impaired strength.
• Assessment of laxity and the use of taping and bracing. 
• Patient-reported outcome measures clinicians can use including the FAAM, CAIT & idFAI

Associated papers and tools:

Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis
http://bjsm.bmj.com/content/early/2016/11/24/bjsports-2016-096858.long

Cumberland ankle instability tool (<24/30) 

idFAI – > 11 – chronic ankle instability (>11) 

Foot and ankle ability scale: FAN ADL(21 items) and FAN sport (8 minutes)

Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium.
http://bjsm.bmj.com/content/48/13/1014

2016 consensus statement the International Ankle Consortium: prevalence, impact and long-term consequences of lateral ankle sprains.
http://bjsm.bmj.com/content/50/24/1493.long

Dr Eammon Delahunt, international authority: Ankle sprain management and chronic instability

Could currently available immunomodulatory therapies modify disability trajectories in patients with moderately advanced and advanced multiple sclerosis (MS)? 
Tomas Kalincik, Department of Medicine, University of Melbourne, Australia, discusses the findings from the MSbase cohort study with Elizabeth Highton.
Read the full article here: http://jnnp.bmj.com/content/88/3/196.

Immunomodulatory therapy in advanced multiple sclerosis

Bruce Forster is the Head of Radiology at the University of British Columbia.  He was previously the director of diagnostic imaging at the Vancouver Winter Olympics and has authored over 80 peer-reviewed publications. In this podcast, we discuss:

-	The role of MSK ultrasound in sports medicine and how to learn
-	Structures that can be imaged and their challenges
-	What to look for when purchasing an ultrasound machine? 
-	Ultrasound guided injections, including evidence behind PRP, stem cells and cortisone
-	Pain science and the role of radiology in treating chronic pain
-	Imaging for prognosis and RTP -when to image?

Bruce is presenting a workshop at the IOC Prevention Conference- details can be found here : http://ow.ly/SFcJ309KUve

Professor Bruce Forster: Using ultrasound imaging in the physiotherapy clinic. Pearls, pitfalls.

Professor Lorimer Moseley (PT, PhD) is Chair of Physiotherapy at the University of South Australia and a professor of Clinical Neurosciences. http://people.unisa.edu.au/lorimer.moseley
He combines Oxford rigour with a laconic and very popular Australian style of communication. In this podcast he addresses the questions: 
What’s new in our understanding of the spinal cord? 
What should we be telling patients? 
Is the ‘hands on, hands off’ debate a useful one? 
How do you feel the profession is performing right now? 
On the subject of what should we be telling patients, he argues we should train them to ask clinicians 3 questions. 
1.	How do I know my pain system is over-protective?
2.	What can I do to retrain my system to be less protective?
3.	Am I safe to move?
You can find his patient website ‘Tame the Beast’ here: https://www.tamethebeast.org/#home
And is previous BJSM podcast was on tendons. It has had >17K listens: http://ow.ly/5OGN30gkaD7.
And here is a link to the Pain Revolution website: https://www.painrevolution.org/

Am I safe to move? Professor Lorimer Moseley: New understanding of pain and focusing on the patient

Jill Cook is BJSM’s deputy editor with particular emphasis on physiotherapy. She is a professor at Monash University, Frankston, Australia, and a renowned international tendon authority. In this podcast she answers questions she is commonly asked about the ‘continuum model’ of tendinopathy that she and Craig Purdam (Australian Institute of Sport) proposed.

See also:
Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy bit.ly/YKmKkM
Is compressive load a factor in the development of tendinopathy? bit.ly/XTvZlk
Jeremy Lewis’s podcast on rotator cuff tendinopathies bit.ly/Nhll0U
Jill’s previous podcast on managing tendinopathies bit.ly/15DM8Qp

Am I safe to move? Professor Lorimer Moseley: New understanding of pain and focusing on the patient

BMJ talk medicine