Tendinopathy  playlist

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

Dr Andrew Franklyn-Miller is a renowned sports and exercise medicine physician whose background includes providing care to the UK Defence Forces and elite athletes. He has published widely in sports medicine and his book, Clinical Sports Anatomy (2011), coauthored with Eanna Falvey and Peter Brukner, is an international best-seller. 

In this podcast he shares secrets from 15 years of experience in treating runners and running injuries.

Gait retraining to reduce leg pain with Dr Andy Franklyn-Miller

If you have wondered about the connection between pain and pathology in tendons, this podcast is for you. 

In this new forum, a BJSM reader takes the hard questions to the experts, Chris Littlewood, who has expertise as a clinician and researcher in the rotator cuff, asks questions of Craig Purdam, who needs little introduction to you, and Ebonie Rio, who has expertise as a clinician in tendons and as a researcher in tendon pain. 

Listen to the answers on the complex nature of tendons and the relationship between pain and pathology, and let us know via bjsm@bmjgroup.com if you have a pressing desire to ask an expert yourself about a clinical issue in a podcast. We are always open to suggestions. 

See also:

Greater glycosaminoglycan content in human patellar tendon biopsies is associated with more pain and a lower VISA score: http://bjsm.bmj.com/content/48/6/469.full

Prospective study of change in patellar tendon abnormality on imaging and pain over a volleyball season: http://bjsm.bmj.com/content/40/3/272.full

Tendinopathy – rehab progression – part 1: http://blogs.bmj.com/bjsm/2013/07/23/tendinopathy-rehab-progression-part-1/

Achilles Tendinopathy: is foot strike important?: http://blogs.bmj.com/bjsm/2014/01/22/achilles-tendinopathy-is-foot-strike-important/

Australian football players’ Achilles tendons respond to game loads within 2 days: an ultrasound tissue characterisation (UTC) study: http://bjsm.bmj.com/content/early/2014/06/26/bjsports-2013-092713.full

Chris Littlewood - Tendons: Where does pain fit in the continuum model?

Professor Michael Kjaer is Professor in Sports Medicine at the Institute of Sports Medicine and Centre for Healthy Ageing in Copenhagen, Denmark. He has published articles in the areas of Sports Medicine and muscle and tendon adaptation at the structural and mechanical levels as well as at the cellular and molecular level. Michael is interested in mechanisms of adaptations to muscle and tendon following exercise, disuse, disease and ageing. 

In this podcast on tendon and tendon pathology he gives a synthesis of seven models of tendinopathy, explains the difference between mid-tendon and insertional tendinopathy, presents his views on the healing capacity of tendons, talks about the (absence of a) link between tendinopathy and tendon rupture, and discusses the various interventions that are used in an attempt to promote tendon healing, including eccentric and concentric exercises. 

Links to articles: 
Heinemeier KM, Schjerling P, Heinemeier J, Magnusson SP, and Kjaer M. Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb 14C. FASEB Journal 2013;27:2074–9. http://goo.gl/MRmulq

Kjaer M. Role of extracellular matrix in adaptation of tendon and skeletal muscle to machanical loading. Physiol Rev 2004;84:649-8. http://goo.gl/tEiirg

Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol 2010;6:262-8. http://goo.gl/s1dpDc

Michael Kjaer on the pathogenesis of tendinopathy and tendon healing

Peter O’Sullivan has two recent BJSM podcasts (see below). In this podcast he shares his thoughts on the recent media attention around Tiger Woods' obvious back pain while playing in the US PGA. 

He discusses what the pathology might be, why the media suggested that Mr Woods’ ‘sacrum went out’. He contends that ‘core strengthening’ may not be the panacea. 

The lessons apply to the management of low back pain, and other pain, in a myriad of settings.

See also
Read Professor O'Sullivan's blog on Tiger Wood's back pain: http://bit.ly/1zaISGz

Listen to his podcast on lower back pain: http://goo.gl/jrQxSe

Listen to his podcast on overtreatment and overdiagnosis in sports medicine: http://goo.gl/vPZ3g8

Professor Peter O’Sullivan (@PeteOSullivanPT) on Tiger Woods’ back and ‘core strength’

With over twenty years' experience, accreditation in Sports Physiotherapy, and a recent PhD in the topic of lateral hip pain, Alison Grimaldi (@AlisonGrimaldi) was invited to this podcast by BJSM’s Twitter community. 

She is a popular conference speaker internationally. Here she walks you through each step of the assessment and treatment of an older patient with right hip pain. She then shares how to assess and treat a younger sportsperson. 

In both cases, Dr Grimaldi emphasizes that compression is bad for tendons that run over bony prominences (trochanter in this case) and indicates how this can be addressed. 

Enjoy one of our most practical podcasts. Recorded at the Physiotherapy New Zealand Conference, Auckland (September 2014) with thanks to the NZ Sports Physiotherapy Interest Group (@SportsPhysioNZ).

Links: 
1) JL Cook, C Purdam Is compressive load a factor in the development of tendinopathy? Br J Sports Med 46(3):163-8. 2012 http://bjsm.bmj.com/content/46/3/163.abstract

2) Fearon A, Stephens S, Cook J, et al. The relationship of femoral neck shaft angle and adiposity to greater trochanteric pain syndrome in women. A case control morphology and anthropometric study. Br J Sports Med. 2012 http://bjsm.bmj.com/content/46/12/888.long

Dr Alison Grimaldi with practical physiotherapy tips on treating lateral hip pain

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

Lower limb tendinopathies with Dr Peter Malliaras

Tendinopathies are a hot topic, and there are lots of new developments in research and treatment. Dr Peter Malliaras, a Physiotherapist with a PhD studying tendinopathy, has a special interest in the treatment of tendinopathy, and treats elite basketball and volleyball, EPL football, rugby, and cricket players, the Royal Ballet and track and field athletes. Peter has also published numerous studies on tendinopathy.

In this episode of the Physio Edge podcast, Peter and David Pope discuss

The latest research on tendinopathy
Different types of loading programs for tendinopathy
Outcomes for various types of loading
Tendinopathy on Doppler Ultrasound or other imaging, and what changes with a loading program
The tendon pathology continuum by Dr Jill Cook and Craig Purdham
Mid portion Achilles tendinopathy
Insertional Achilles treatment
Patellar tendinopathy treatment, and a loading program for this that may challenge your preconceptions!
Tenosynovitis
Biomechanics contributing to tendinopathy
Return to sport following tendinopathy
Injury reduction/prevention
Injections
Peter shared so much great info on tendinopathy, check it out now on episode 23 of the Physio Edge podcast

Show your love for the podcast sponsor, Clinical Edge, and their fantastic face to face and online education. Get 20% off your first months Clinical Edge membership with the code “PHYSIOEDGE”.

PE #023 Lower Limb Tendinopathies With Dr Peter Malliaras

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 Episode 41 of the Physio Edge podcast, [Dr Christoph Spang and I discussed how Plantaris may play a role in Achilles tendinopathy. In this episode of the Physio Edge podcast, I discuss with Seth O’Neill how you can identify Plantaris involvement in your patients, and adjust and progress your conservative treatment of Achilles pain and tendinopathy with Plantaris involvement.

We discuss:

- What indicates Plantaris involvement and helps you differentiate from mid portion Achilles Tendinopathy
- Where do patients have pain with Plantaris
- What history do patients with Plantaris involvement or tendinopathy present with
- Objective tests and findings for Plantaris
- Biomechanics contributing to Plantaris tendinopathy
Is treatment successful for Plantaris
- How to treat Plantaris tendinopathy and involvement in midportion Achilles
- Running adjustments
- Taping
- Manual therapy

Physio Edge 042 Treatment of Plantaris & Achilles Tendinopathy with Seth O’Neill

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)

Tendon Neuroplastic Training With Ebonie Rio

Proximal hamstring tendinopathy (PHT) occurs in athletes, runners, weightlifters, and other athletes, as well as more sedentary patients, causing pain at the hamstring origin and limiting your patients ability to sit, run and continue to be active.
There are a number of structures that can contribute to pain in this area, and in this podcast, Tom Goom and David Pope discuss how to clearly identify PHT and differentiate it from lumbar spine referred pain, hip pain, sciatic nerve pain and other conditions.
Tom recently released an article in JOSPT on Proximal Hamstring Tendinopathy: clinical aspects of assessment and management with Peter Malliaras, Mike Reiman and Craig Purdam. We explore this article, and the research around PHT, and cover in detail:
	•	Subjective clues to guide you towards diagnosis
	•	Aggravating factors and 24 hour pain patterns
	•	Differential diagnosis
	•	Lumbar spine pain
	•	How the lumbar spine could contribute to development of PHT
	•	Hip pain
	•	SIJ pain
	•	Sciatic nerve pain
	•	Development of PHT
	•	Central sensitisation
	•	Diagnostic tests for PHT
	•	Hamstring tests
	•	Other assessment tests
	•	Functional tests
	•	The value of palpation
	•	Tests for involvement of the rest of the kinetic chain
	•	Running assessment/gait analysis
	•	Testing load tolerance
	•	Biopsychosocial aspects of tendon recovery
	•	Other advice for patients
	•	Whether stretching is helpful
	•	When your patient can return to running
	•	Cross training
	•	Does manual therapy have a role in the treatment of PHT?
	•	Starting treatment (Stage 1)
	•	When and how to progress rehabilitation (Stage 2)
	•	Further rehabilitation progressions (Stage 3)
	•	Advanced exercise progressions for high load sports
	•	Exercises you can incorporate during the various stages
	•	How long recovery will take
Links
	•	Free webinar with Tom Goom
	•	Download the free handout summary of this podcast
	•	Tom’s website - Running Physio
	•	Tom on Twitter
	•	Running Repairs courses with Tom
	•	Article in JOSPT on Proximal Hamstring Tendinopathy: clinical aspects of assessment and management
	•	JOSPT
	•	Peter Malliaras
	•	Mike Reiman
	•	Craig Purdam
	•	VISA-H
	•	Become a Clinical Edge member to access Tom’s webinar and other great online education
Tags: running, hamstring, tendinopathy, tom goom, podcast, proximal, peter malliaras, craig purdam, mike reiman, treatment, assessment


Physio Edge 046 Proximal Hamstring Tendinopathy With Tom Goom

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

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!

In part 1 of two podcasts, Dr Ben Kibler, international shoulder authority, shares top tips on examination and diagnosis of the tennis player.  (Part 2 will focus on baseball pitchers)

Dr Ben Kibler, orthopaedic surgeon and medical director of Lexington Clinic in Kentucky is a world expert on management of shoulder injuries with a particular focus on the role of the scapula (scapular dyskinesis).  He has held regular ‘scapular summit’ meetings of experts in his hometown of Lexington, Kentucky, USA. The most recent summary of that meeting can be read here: http://bjsm.bmj.com/content/47/14/877 

In this podcast, we discuss:

•	Briefly how Dr Kibler, a surgeon, learned about biomechanics
•	Examination of the tennis player’s shoulder including how to perform a biomechanical analysis
•	Simple tests to recognize abnormal asymmetry in the tennis player
•	Diagnosis of injury in tennis players; search for culprit (the real cause) – don’t just incriminate the victim
•	The rise in the double-handed backhand in tennis and how it has increased the incidence of ulnar wrist injuries 
•	Role of communication within the multidisciplinary team: how much should the physician know about the biomechanics?
•	Two tests commonly used to assess shoulder function – the Scapular Assistance Test (SAT) and the Scapular Retraction Test (SRT).

Remember to keep an eye out for Part 2 – management of the overhead throwing athlete. You can meet with Dr Kibler in person at the AMSSM annual conference. May 9-13, 2017, San Diego. It’s a prime spot on the sports medicine calendar. https://www.amssm.org/Content/pdf%20files/BROCHURES/2017_Annual_Meeting.pdf

Dr Ben Kibler:  Clinical assessment of the tennis player with a focus on the shoulder

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

Whether to opt for exercise treatment, new ‘biological therapies’ like platelet-rich plasma (PRP), or surgery is a clinical challenge. Sweden’s Professor Håkan Alfredson has unique experience in considering these options for patients with Achilles pain. He has 15 years experience as an international leader in sports and exercise medicine.

In this podcast, he tells BJSM’s editor Karim Khan how to manage both straightforward (0.37) and complicated (7.34) Achilles tendinopathy. He shares novel insights into the contribution of the aberrant plantaris tendon to chronic medial leg pain (12.40).

Prof Alfredson also provides a memorable clinical story to underscore the effectiveness of heavy loading eccentric training in one particularly stubborn patient (3.49). He argues against the use of PRP (17.37) and considers cortisone to be a short-term fix but long-term liability (15.24). The podcast concludes with discussion of both jumper’s knee (19.35) and lateral elbow tendinopathy (24.44).

Related paper:
Midportion Achilles tendinosis and the plantaris tendon http://bit.ly/11y79bc

Related podcasts:
Robert Jan de Vos and Adam Weir on platelet rich plasma injections http://bit.ly/JdmFkJ
Professor Jill Cook on managing tendinopathies in 2011 http://bit.ly/15DM8Qp

Treating tendinopathy with Professor Håkan Alfredson

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

Jill Cook on the continuum model of tendinopathy

Lateral epicondylalgia, often referred to by patients as tennis elbow, has a range of treatment options available to the clinician. A group at the University of Queensland, Australia, headed by Bill Vicenzino have been investigating short and long term outcomes of different treatment modalities. Last month, they published an RCT in JAMA examining the effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia.

Professor Jill Cook asks the hard question - is it time to drop corticosteroid injection from the treatment options for tennis elbow?

Tendinopathy playlist

Ioannis Poulis