Dr Peter Malliaras has been a clinical researcher in the field of tendinopathy pathology and rehabilitation for more than 15 years. He has contributed to more than 55 peer review publications surrounding tendinopathy and as a clinician, sees around 30-40 tendinopathy clients per week. I pick his brain around: The latest research in tendon pain and tendon rehabilitation What management has shifted in the past 5-10 years What we can conclude with shockwave. PRP and cortisone injections. Best management from acute to chronic When to be sent for scans What other structures could be contributing to pain Your Facebook questions also get answered! To visit Peter's website head to: https://www.tendinopathyrehab.com/ For Peter's twitter go to: https://twitter.com/DrPeteMalliaras (Apple users: Click 'Episode Website' for links to..) Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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Talking Tendons Five, with the all-in-powerful Peter Maliaris. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, and smarter runner. My name is Brodie Sharp. I am the guy to reach out to when you've finally decided enough is enough with your persistent running injuries. I am a physiotherapist, the owner of the Breakthrough Running Clinic and your podcast host. I'm excited to bring you today's lesson and to add to your ever-growing running knowledge. Let's work together to overcome your running injuries, getting you to that starting line and finishing strong. So let's take it away. We are concluding this mini-series with a big one. We have Peter Maliaris on the podcast today to discuss all things tendons amongst the physios who listen to this podcast. You will be very familiar with Peter. For those who are just runners and listening in, he's a big deal. He is. Oh, let me just pull up his website because I can deliver his bio. So Dr. Peter Maliaris has been a respected and leading tendinopathy researcher. and clinician for the past 15 years. In 2006, he completed his PhD in tendinopathy, identifying novel risk factors. And since has undertaken his postdoc research in UK and Australia, he has co-authored over 55 peer reviewed publications, which have all been related to tendinopathy currently. He has research affiliations with Latrobe Uni and University of Melbourne in Australia. and Queen Mary University in London, and is involved in numerous tendinopathy clinical research studies and maintains a strong clinical focus, specializing in different tendinopathy cases for over 10 years. He sees around 30 to 40 tendinopathy patients per week and regularly consults with elite athletes. He has his website, which is tend which is where I've got that info from. And he wants me to share that out with you guys. If you have any other information after this interview, if you are finished listening to this and want to find out more, that's where you can go. We covered a lot in this podcast. We covered Peter's research, what he has done in the past and what he's doing now. What is the essentially what's the most effective management for tendinopathy? Where are we at with the research? Where are we at with shockwave, PRP, other injectables? Where's the relevance in terms of. receiving scans, what other structures might be at play, and then I haven't really done this year on the podcast, but I got some Facebook group members to submit some questions and we went through those questions today at the end. A bit of a warning moving forward, I will be publishing some episodes very frequently this week, so take your time with getting through them. We did have to reschedule Peter's interview. by a week or two and in the meantime I've pre-recorded a lot of interviews and so I just wanted to keep this tendinopathy or talking tendons one to five all bunched together and therefore as we go back through the archives it's a lot neater. So yeah, a bit of warning, there will be a lot of episodes coming out in the next two or probably three weeks. I hope you enjoyed this, this was a big one for me. Um, I was really, really excited to talk to him and the outcome was more than I'd hoped for, so let's bring on Peter. Thanks for coming on by the way. Let's start with, um, how you ended up in the field of tendons. Let's start with that. Sure. Uh, so, um, I worked as a, uh, I worked as a physio for, uh, probably five years. Um, since when I finished and I always, I've always been someone who questions everything, like a skeptic type person and I ended up just thinking what am I doing when I first graduated for a few years in terms of am I actually helping people, do I know what I'm doing, to the point where it sort of led me towards reading literature and then just thinking about doing a PhD and that's when I decided to do it. And basically then it was just serendipity more than anything, just the right place, the right time. And I was interested in attendance, but I guess the PhD really brought that to the next level. Cool. And is there, what sort of past and current research have you focused on? The past research was really about... understanding pathology, so the imaging and the imaging, how the imaging changes over time. So one of my studies contributed to the continual model, the thinking about how the pathology changes. And that was one that I did with Jill Cook as part of my PhD. So that was sort of heavily influenced by Jill and sort of some of her thinking, which was along the lines of pathology and pain and some really good studies there, but my sort of interests have gone away from that a bit more towards I'm interested in, very much interested in exercise now. So probably the best way to describe the research I do now is a lot of it is trials looking at exercise and education and how we can optimize those interventions. And then the other part of what I do is from a research point of view is looking at, I've got a biomechanics sort of lab. Clayton campus in Monash where we look at biomechanical research. So look at impairments. So are there sort of impairments with rate of force development and strength and balance and how can we then again optimize our interventions to address those? Okay. So you're using that to maybe perhaps identify deficits in strength or power and then seeing if there's any correlation or whether... treatment and management should be focused around those deficits? Yep, exactly. So we really don't have a lot at the moments of knowledge about what, you know, if you're looking at an Achilles patient, for example, how they present what we should be focusing on in terms of managing these people, what deficits remain. So if you look at the exercise literature, people just do quite generic things without much thought to them. And people still tend to get better, but if we did more specific things that were targeted towards impairments, maybe we would have better outcomes. Okay, and that's what the literature is aiming for is to have a bit more of a targeted exercise prescription and therefore theoretically recover a lot quicker and more effectively. That's part of it. The problem with that sort of thinking is, I guess it sort of opens the whole area of the mechanisms of exercise. So how does exercise work? Is it that we're targeting strength and people just, if they're weak, make them strong and their pain goes away. It's not that simple. If they've got impaired power, we improve their power and their pain goes away. I think there's a, a slight disconnect between what happens from a functional point of view, people getting more power and strength, and what happens from a pain point of view because pain is so multifactorial. So the mechanisms there could be, you know, changing their thought processes and their beliefs rather than, or in combination with some of the other neuromuscular factors. So I think in trying to get someone more functional, we have to think about power and strength. That's a different consideration. Obviously, power and strength may be important, but a lot of other factors are important as well. Okay. And you did mention there's some focus on education when it comes to the pain management. Yeah, absolutely. So I've just sort of come to the realization probably in the last five years that our education is just non-existent when it comes to pain management. development of education interventions. So one thing that I've spent a fair bit of time on in that time is trying to develop education that is going to address the needs of people with tendinopathy. So we've developed our education intervention for people with rotator cuff-related pain, and we're testing that in a trial at the moment. And the way we did that was we looked at the literature. and clinical practice guidelines, and we looked at all the types of education they recommend. And then we looked at interviewing a whole bunch of shoulder experts and said, what education do you think we should include for people with rotator cuff related pain? And then we interviewed a whole bunch of patients, and we also asked them, you know, with that condition, asked them what their education needs are. So that... That's brought us now to a point of developing this education, which has taken probably a couple years. But I think we need more of that. We need more, because if you're a clinician and you're seeing a patient like this, what do you educate them about? Obviously, people are all individual and you're going to target different things with different people, but you do need some sort of framework to base your education on. That will tie in really well when I get into a couple of my later questions, but you've sort of described the gap between delivering the correct education and how it's kind of emerging. What else have we seen in the last five to 10 years or so that's been a radical change in the way that we manage tendons? I would say probably nothing that you could describe as radical and very different. I think probably isometrics might be one that qualifies, but what happened was we had this isometric study that came out in 2013 that showed that isometrics are helpful for reducing pain in the short term. And it also in parallel to that was a reduction or a reversal in inhibition in the brain, in the motor cortex. And that sparked a lot of interest in isometrics. People started using it a lot. And now, you know, science is self-correcting and we're seeing now that maybe we're a bit too enthusiastic and maybe there isn't that much difference in the isometric, in the effect in... short-term pain isometrics versus other exercise, it seems to be that you'll get similar responses if you just load people progressively. So that has been a really influential thing that people have taken on board a lot and I guess it's one of those things that happens. often run with things and we just don't have the evidence to back it up. But aside from that, we're just doing the same stuff and hopefully getting better at it. But the key to management of a tendinopathy is a good progressive exercise to bring about tolerance of the tendon as well as good education to couple with that and not overdoing it with things that can aggravate like... you know, loads that are high for the tendon. And that's, those basics really haven't changed. And if you scratch the surface below those things, and aside from those things, to all the adjuncts like shockwave, and injections, and surgery, and you know, everything else, the evidence is really, really poor. And we really don't have good evidence, or anything that is, you know, we can strongly recommend. aside from exercise and even the exercise evidence isn't that good. Hence why we're trying to improve it. So I, you know, things that things are improving. It's probably sounds very, you know, pessimistic, but things are improving, but I would say very slowly. Okay. And just to recap a little bit, just for those who unaware. So the isometrics being an exercise where you hold on to the weight with out movement. So the tendon is under load without going through any range of movement. And so what was, well, what was discovered was if you were to hold onto those heavy loads without movement, and then after you do a certain desired amount of holds around 30, 45 seconds, the pain might diminish. And so we got excited about that and focused on the isometrics for a long period of time. But then as more evidence started emerging, realizing that loading up the tendon through movement could be having a similar effect. Am I right in saying that? Yes, yes, yep. Okay, great. And so what can we say currently around things like shockwave and PRP and other injectables? Because I know these... treatments do get thrown around a lot and people are a bit unsure of if they're eligible or if it will be most effective for them. So based on the research that's out there at the moment, what can we conclude? Yeah, look, it's a real tricky area. If you look at shockwave therapy, for any treatment, we need to know whether it works over and above placebo. And for shockwave, there's studies out there that have compared it to placebo. And in some studies, it shows that it's no different to placebo. In others, it shows that it has more of an effect on outcomes like pain and function. So it's a bit uncertain if it works, and it's probably similar for PRP. the blood injections that people offer, they don't necessarily well. A lot of the high quality studies show that there's no difference in placebo. So it's important to, when you're reading literature as a clinician or a patient, think about the comparison. Because if you compared as some studies have PRP to steroid, in the long term, a lot of those studies have PRP is better, but that's probably because steroid is harmful in the long term. So you need to be very careful of the comparison and placebo comparisons for things like this are really important, I believe. We need to know whether they work over and above doing something like a placebo, which controls obviously for the placebo effect. And you know, we just don't have that evidence for anything. convincingly in tendinopathy aside from it could be argued exercise is the only thing that we can say, okay, this probably does do something. But even that is not the strongest evidence. So we have a long way to go. Yeah, absolutely. And it'd be very tricky to design such studies where there is a control group or a blinded group that thinks they're getting the treatment. in reality is not so that you can have a good comparison of what a placebo is. But it also, if you are having a blinded control group, it's even knowing like how powerful the brain can be with placebo can be quite tricky if you have, say, someone who, a group that undergoes shockwave, but then another group that doesn't, but thinks they are getting the correct intervention. the power that the brain can have to actually reduce pain or help with management. And so it's going to be extremely tough. Yeah, yeah. That's why placebo is so important. So if you look at why people get better over time, there's lots of different reasons. One could be the treatment itself. One could be just natural history and time. And that's also a powerful effect. As you say, the power of the mind, which is placebo, which is a physiological effect. We know that if we think we're receiving something that's going to help us, we do get benefit from that. So that's a physiological effect. And that's what you're controlling with placebo comparison. But if you've just got a control group, which could be a waitlist group, so they're just waiting it out, or it could be no treatment control, or it could be minimal intervention active control, where you just give them a pamphlet and say, see you in 12 weeks. They control for natural history, so people are just getting better naturally over time, but not for placebo because they know they're not getting the right treatment or the active treatment or the better treatment. So placebo is important if you want to know if something works over and above, just as you say, the sort of power of the mind. Okay. And you did mention before that you delved into... scans and how relevant they can be. Do you recommend any type of scan over another at the moment for someone who does have a chronic tendinopathy? Yeah, look, that's a good question. I was part of a consensus group that met at the last international tendinopathy scientific conference. It was the end of last year. And what we, one of the things we talked about was the diagnosis of tendonopathy and how can we, what should we be recommending for people who are clinicians and also people who are doing research for how we should diagnose this problem. And what we pretty much unanimously decided or agreed on was that you don't need, you don't need a scan to make a diagnosis of tendonopathy. problem, so you diagnose it based on how it behaves, the pain behavior, where the pain is, what aggravates the pain, and some of the other clinical tests that we can do. So you don't need a scan. So you definitely don't need a scan. We can diagnose confidently without a scan. Where a scan probably does fit in is when you have failed the first line treatments that we offer, like the education, the exercise we talked about earlier. then you can start to think about a scan and that might be then leading to some other intervention. It could be an injection or it could be, it's important to rule things out. If you're not getting better, there might be something else that has been missed or not to be alarmist and to get people to worry. But often the diagnosis is very, we're confident of the diagnosis without a scan. getting a scan if you're not responding is a reasonable thing to do and that's sort of where it fits in. But what people have to remember is that, and this is the difficult thing, what is on the scan? The scan will show lots of things, most of them are normal, age-related, age-related changes. You can have some, you know, what they would call degeneration in your tendon or some thickening in the tendon. And that's just a normal age-related process. It doesn't mean you're gonna have pain. It doesn't mean you have pain. It doesn't mean your pain is coming from that. And that's the hard bit for people to get around their head. The clinical diagnosis is absolutely key. Obviously, if the pain is consistent with a tendon problem and you've got the degeneration or whatever else, sort of increases our confidence that, you know, this is a tendon problem. But the diagnosis, as I say, is clinical. And that's what we really look at. I guess where imaging is important is, you know, what we call differential diagnosis. So what else could be, you know, there that we may be able to target? So for example, around the Achilles, you might see that there's some, you know, flawed around the sheath or there might be some other problems around the tendon that you can potentially then look at and say, you know, that's a useful indication for imaging. Okay. While we're on that topic, you did mention like the tendon sheath, but are there any other structures like within the tendon or surrounding the tendon structure that could mimic? tendinopathy like have the same type of symptoms? Yeah, look, there are. So tendons usually have a fat pad around them. So for example, the big fatty tissue around the teletendon, there's often a bursa. There's often other tendons like the tibialis posterior tendon around the ankle or the plantaris tendon around the Achilles. you do get these tissues that can give you some symptoms around the same area. But I guess what people are moving towards is more an appreciation that the tendon pain often involves multiple tissues. So if you look at, say, an insertional Achilles problem, you often see, if you look at an MRI or an ultrasound, you see changes around the tendon. you see some changes in the bursa, you also see some changes in the bone. So it's what people call the emphasis organ. It's all, all those tissues are so close together and once you have pathology, it tends to be across all those tissues. And we have no way of knowing which one's causing the pain. So in a way, you treat them in a very similar way when it comes to exercise and loading. There may be some slight differences in terms of You know, other things you might do. So if you've got an inflammatory tissue component like a parotinium, then you might do some, you know, anti-inflammatory things like some topical anti-inflammatory. But for all intents and purposes, a lot of the rehab is based on just good, progressive exercise based on their tolerance and based on what positions they can tolerate and what type of loading and intensity of loading they can tolerate. And that's regardless of some of those diagnoses around the area. But yeah, there are lots of differential diagnoses. There's probably a list of 10 or 15 for each of the tendons that you commonly see. Okay. And like I said, you might recommend scans for someone who is going through a really good rehab, really good program, but not responding the way we're expecting is... It could be something like a parotinone or a sheath or a bursa or other structures that might be impacted. Maybe if we identify those and it fits the relationship of what they're presenting with, we can come up with more effective management plan and maybe do some anti-inflammations for a little bit, just if there is an inflammatory component to settle things down. progressing through your loads in order to tolerate more and more? Have I got that? That's pretty much true, but what I would say is that from day one, the initial assessment, you should have a pretty good idea of what diagnosis is. So day one, you'll get an inkling from your clinical assessment that maybe there is a plantarus or paracetam component or something else here. you may get that idea from early on, in which case then you can treat them for that. You can treat them as if you, you know, clinically that's your diagnosis, you treat them for that. You can, if you're not sure, look at some imaging earlier on to say, okay, I wanna confirm this clinical suspicion I have that they may have a plantarid or something else, but only do that. if it's going to change your management. So if you are going to get, say, an injection or do the anti-inflammatory treatments or do something different that you think is going to help them. But if you're not, then there's no need to. So wait the 12 weeks, and if they're not getting better, then look at imaging at that point. Brilliant. I think it's also important to mention, if we're talking about scans and the findings that might come back, to it, not just for tendons, but for any injury, there might be some degeneration here and there. And the scans, if it's like an MRI and they're scanning a whole bunch of structures, it will come back with a lot of findings that might be incidental and might not be contributing to your symptoms. It's, it'd be very nice if, you know, someone got scans and they weren't allowed to look at it until someone who's very proficient in. identifying and knows your symptoms and knows your presentation can interpret it the way they want to communicate to the client, but it's not necessarily the case. It's usually straight to a GP who reads it out and comes up with the findings and ingrains a lot of maybe anxiety or fear with a lot of people. Yeah, I absolutely agree. One of the areas that I'm really interested in researching at the moment is we're looking at how reports of how shoulder rotator cuff related pain is reported, how that affects the patient. So someone said, look, you've got this tear, full, you know how they have all these descriptions like full thickness, you know, they have all these, all these descriptive terms that sound so serious. How does that affect the patient? And so we're doing some, one of my students is doing some qualitative work interviews. So we're accessing scans from a radiology place and then we're gonna, you know, the ones that have got these features, interview people and say, what, you know, how did that affect you? And what did you change your behavior because of it? Yeah, right. Makes you think, doesn't it? I have a question written down here that says, oh, what's the best management for a tendinopathy that's like, say two weeks old compared to six months compared to say two plus years. I'm not too sure if your answer is just going to be loading and progress from there. Would you have anything that you wanted to add based on the correct response to management at those timeframes? The only thing I'd say is that it's the management's always based on the presentation at that time. and that could be things like primarily their pain and function. So if they're really, really weak or they've got really poor power or they're really fewer avoidance, then you'll target those aspects. If they've got really high levels of pain, so you do some loading or exercise with them and they're reporting really high pain or they report high pain day to day when they're doing things, then you would probably use a different approach. Generally, there's two phases of the rehab. One is manage their symptoms, get it down to a tolerable minimal level and the second phase is then progressively re-engage with all the activities that they may have had to stop because of their pain being so high. And so if regardless if they've had it for two weeks or 10 years, the approach would be the same based on those factors. Okay. And if we're thinking about the continuum model of pathology and a tendon is a bit more advanced and they're in that degeneration phase and there might be some unhealthy parts of the tendon. Does that change management at all? Um, not really. So the actual pathology on the scan doesn't change our management. So if we're confident it's a tendon, then we try and load to bring about you know, tolerance and better ability to load that tendon, you know, you could say better capacity, but whether it's a degenerate tendon or one that looks a bit worse on a scan, or, you know, as the continuum model would say reactive, we don't really, we can't because we don't have any evidence that we should be doing one thing for one and different things for the other. So it's all, it's, it still is based on pain and function. Yeah. I think that's a, um, it's reassuring for people to know because for someone really undergoing a lot of say pain and like their symptoms are quite high and they're lost a lot of their, uh, like I say, re-engagement with maybe running or something with the community or even just day to day up, downstairs, that sort of thing. Yep. The management is still quite the same. If they are. If you're seeing a client and they do have years of say chronic patella tendon and they are really anxious and you can tell that the brain like rewiring might have a lot to do with it and they're really, yeah, they've just, what's the word, they're just really scared about movement. Is there a way you can use your communication or that communication framework that you talked about before? in order to educate them what's happening with the tendon and sort of re-steal a lot of that reassurance? Yep, I think that's really critical part of the role that we can play. So I've got in this education type resource that we've developed, we have lots of things that we target in there you know, not aggravating it and trying to, you know, reduce activities in the short term that might be aggravating us. And there's things about the pathology itself and the risk factors. But then there's also lots about pain and understanding that pain is not equal to pathology or damage. That, you know, you can have a little bit of pain when you're doing activity, but as long as it's not flaring up and that sort of thing to reassure people, that, you know, and also talking about pathology and that even if there is a tear there, it doesn't necessarily get any worse. And when there's pain, you're not making the tear worse. So all those things can help fear, avoid and type behaviours. And it's a very important part of education for these people. And as you say, everyone's slightly different. So for some people, that's going to be a really important component for other people. They're not worried at all. In fact, they just... have the opposite response. Some people are probably doing too much. So it will be very individual. There's two good points I want to reiterate there. And I did a little mini series on the pain science earlier in the podcast. So people might be familiar with this, but just getting that point across that pain doesn't always equal pathology. If you do have low amounts of pain or if you have really high amounts of pain, there's no correlation between, um, the actual structure damage or anything that's going on there. But also it is okay, um, under the right guidance to load the tendon, even if it is sore. And I think you might agree that there's ways to overload it and overdo it if there's pain, but there's also a really sensible dosage under pain, which can be really easily managed, but actually help the recovery of the tendon. Would you agree with that? Yeah, absolutely agree. Absolutely agree. So it's finding that balance, as you say, definitely. Okay. I wanted to finish up with a few Facebook group questions and we'll see how we go for time and see if we can get through all of them. But I want to start with, Julia asks, how many times a week do you recommend for strengthening once there's... I think she was saying she's recovered from her tendinopathy, but she just really doesn't want it to reoccur or pain to increase. So how many times a week would you recommend a strengthening program to keep everything at bay? Yeah, that's a really good question. We don't really have a good answer that's placed in evidence for that, but some patients seem to be able to get away with nothing. So they stop completely and they're fine. Other patient, I generally advise do something at least once a week to maintain. If it's not in your nature or your routine to be doing stuff like going to the gym or doing exercise at home or you don't go to an exercise classes, you can incorporate things there more easily if you do two or three times a week. But for people who want to do the bare minimum, I think once a week is fine. It's just about maintaining your strength. once you're back to your activities, generally people don't have, you know, that many problems. Okay. I think that that's a good point that you made. It's about maintaining the strength. Cause if we're looking at kind of a load based model and making sure we're not excessively exceeding that load, someone might do strengthening once a week and still maintain the strength that's required for their weekly dosage or the weekly kind of power and strength that they're going through. but someone might be also being quite intense in the gym or increasing for a marathon or something and might need strengthening more than once, maybe two or three times a week, but it all just depend on the circumstances and how much strength or load you're willing to put through that tendon and just keeping the strength slightly above those requirements I think is a really good point. But you also quickly mentioned I think I'll just add onto that. There's a certain type of people that just develop tendinopathies. I don't know if it's a DNA type of thing or genetics or something, but you do have a certain type of person that just not only just within one tendon, but just will get bilateral tendinopathies or they've just overcome a patellar tendinopathy. Now it's Achilles on the other side and they just seem to get them. And I think if you're that type of person, then... strengthening might be a little bit more higher on the priority list. Would you agree with that? Yeah, look, there's, uh, Ted not fees multifactorial in its, um, in its sort of risk factor profile. So there are people that, you know, on the young end of the spectrum who are just dominated by load, uh, and they're just doing a lot of jumping and running. Um, and then there are people on the older end of the spectrum who've got all these other comorbidities like I could have metabolic, uh, problems or they might have begun through estrogen and have begun through menopause and have a loss of estrogen. There might be people who, you know, age is a risk factor, obesity, there are so many risk factors that are not related to load. But as you say, there's also genetic type factors. So you can have someone who's young and they have had three or four different types of in five years or something and you start to think they've probably got a previous position there and there's not much you can do about that unfortunately, but you just, you know they're going to be difficult to manage. Some people are more difficult than others. Certainly there are tendon patients that don't respond well and take a long time to get better. I mean, I've seen, sometimes I see tendon patients for over a year. and they just slowly trickle away and get better over time. But, and that's part of our job in terms of motivating people. It's not easy to be sticking to your rehab and be motivated for a year. And that's sometimes what it takes. Yeah, laying down those expectations. We'll move on. So thanks Julie for asking that. Lance has Achilles tendinopathy and was wondering if treatment needs to be changed if symptoms arise from the insertion point mid portion, is there any change in management that can be more effective? Yes. So there's a couple of key things. One is you don't want to be doing exercise over a step right into dorsiflexion. So hanging the heel right over a step if you've got an insurgical problem, because that can aggravate it. The second thing is you probably want to be very careful with the type of shoes you're wearing and thinking about higher heeled, well not some sort of pitch on the shoes so you can try and take stress off the incision. But having said that, it also works for mid-portion Achilles very well, having highest heeled shoes because it takes pressure off. And that's the idea with the heel wedge. The heel wedge is designed to take some pressure off. I was part of a group that did a trial out of La Trobe Uni that is just about to be accepted hopefully. And the comparison there was... eccentric training, which is a popular type of exercise for Achilles to Nocty and then compared to just the heel wedge, nothing else. And what we found in that trial is that there wasn't much difference between the groups, but there was there was some outcomes that were actually favoring the heel wedge. So I use heel wedges a lot, probably started to use them a lot more after the those findings. And quite chunky 1.2 The treatments are quite similar. There's talk about differences in outcome. So people think, oh, the insertional ones are harder, but I don't know about that. The evidence isn't very strong one way or the other. They both can be quite difficult. They both can be difficult. The principles are pretty similar for both of them. Shockwave therapy is an option. Some of the injections. So, so overall, aside from the exercise loading, it's pretty similar. I need to ask the question because, uh, some others might be thinking the same thing when you're talking about these heel wedges, if you have tendon pain on just the right side, do you need to put the heel wedges in both shoes? Yes. Yeah. It's, it's always good to have them in both shoes because, um, you just want to even, you know, be even, even as possible and not, um, uh, put any. unexpected loads, other load through your body. But generally, yeah, the ones I use are 1.2 centimeters high. So they're pretty, they're reasonably high here, we're just, you want to use two. Yeah, perfect. Linda asked, at what point should we get a scan? But I think we answered that already. I think it was more around if we're not responding to a really good rehab plan. Perhaps we could get scans if the diagnosis is different, if it would change our management, that's when we should get scans. Is there anything you want to add to that? That's perfect, yeah, that's exactly what I would say. Yeah. Okay, perfect. So we've got Donna and Amanda, who kind of asked the same question or were intrigued about the same question. Is there a point where full recovery is not likely and treatment is directed more towards symptom management rather than like a full? recovery. Sorry, say that again. It's kind of like, um, do I have to, if I've got a really bad chronic tendon for years and years, does it get to a certain point where I just have to live with it and have to put up with it or is there hope for them? Yeah. Um, they look, I, I routinely see people with 10 year history of problems and they feel like that's never going to get better. So But it does. And I have had some that have good recovery, others that don't have so good recovery. So it's hard to predict, but I think it is possible if you do all the right things for long enough to get rid of pain completely. I do believe that. Yeah. Okay. Very good. And just rolling through these, Liz asked how to handle a dual problem. of having both chronic perineal and posterior tendinopathy. So like the same foot, different sides of the ankle. If you're trying to manage both tendons, is there any change in management that we need to do? What were the tendons? Perineal and... I think she's put perineal and posterior tendinopathy. So maybe like Tib post. Tib post, yeah. Ah, yes, so both sides of the ankle. Look, they are very different problems with... very different types of sort of, you know, rehabs that you would do for them. I guess with all the management you would start with, what are the drivers for this? Why is this person getting this? Is it, like we said, some metabolic stuff or just age combined with, say, menopause or something else? Or is there some biomechanical things we can change like footwear or, you know, the strength and flexibility around the leg? So I think starting with that is probably But yeah, it's always going to come down to those factors. But you would then start to try and bring about tolerance to both of those tendons. And the overall principles are the same, but yeah, there'll be different approaches for both of them. Okay. I'll just write that down. And so Trent put in a message here and he got in just the nick of time. So he's asking, there's a lot of stuff coming out more recently around strengthening foot intrinsics and he was interested to hear your thoughts on relating this to Achilles tendinopathy and do you feel like it's important to combine foot intrinsics with Achilles tendinopathy management and if you implement that yourself? Yeah, look, that's a good question. I don't think it hurts but I don't think it's absolutely indispensable. I think for a lot of people they get lots of good proprioceptive input from something like doing intrinsics and for some people it may benefit them. But I don't think it's absolutely indispensable. I do use it for some people. If I think that the foot is, there's a component of the foot for a lot of TBL's posterior patients, but I don't think it's indispensable. point too is that if you're doing heavy, heavy loading, you'll get some strength through the foot. You have to, because the foot's a lever and it's loads going through it, but you may not get the proprioceptive input. And that's where I do things like heel to toe walks and various foot drills. And they sort of, they would, I would argue, give you some proprioceptive input anyway. So I don't go a lot to just the pure sort of foot. you know, intrinsic type basic exercises. Just, yeah, that's just sort of a personal thing, I guess. Okay. And would that be someone who's you've identified as lacking proprioception in your testing? Well anyone who's got a foot component to it, so say they've got some pronation when they're walking or they've got, say, yeah, so you wouldn't... you wouldn't really look at the proprioception so much, but more the pronation, biomechanical foot component, then I would probably look at their foot intrinsics, as well as say if they're weak around inversion, tip-post type people, then I would add in some sort of foot strength as well. Okay, very nice. We're going to finish with the Facebook group questions. So thanks to everyone who submitted those. As we finish up here, are there any key takeaway messages for anyone with a chronic tendinopathy that a message maybe we haven't got across today that's really important, or do you think we've pretty much covered everything? I'll probably say the message I give to most patients is be patient and just do the really simple things really well for a long time, and most people get better. Don't stress too much about it. Do the simple, do the simple things really well, persevere with them. Don't jump to like, you know, your quick fixes. And unless, you know, don't jump to your quick fixes unless you've done the, done the rehab and everything else really well. So I think it's, I think, I think it's about patient and mindset, patients and mindset. Very good. And I think having the right health professional that lays down those expectations as well. is pretty key so that the message gets across in the right educations there. Brilliant. I think we covered a lot of ground here. Peter, I want to thank you for coming on. You're doing really fantastic things in the world around tendinopathies, particularly for this running population. And it can be very, very chronic. It can be very, very debilitating for a lot of people. I know on social media and on Facebook and stuff, people just post, I've had certain tendinopathies, this is what I can't do now. And it can be such a debilitating condition if you let it. And thanks for putting out your research and sharing your knowledge, because the more knowledge we have, the more effective we can be with our treatment and management. So, yeah. Thank you. And thank you for disseminating. I think it's very important job to also get the message across to patients and clinicians. So thanks for having me on. You're very welcome. Wasn't that awesome? I thought I would just quickly mention I have added Peter Maliaris' social media handles and his website on the links in the show and note links, so feel free to follow him on there and yeah, that's all I had to say. Enjoy your run today, take care. Thanks for listening to another episode of the Running Smarter Podcast. I hope you can see the impact this content will have on your future running. If you want to continue expanding your knowledge, please subscribe to the podcast and keep listening. If you want to learn quicker, jump into the Facebook group titled Become a Smarter Runner. If you want tailored education and physio rehab, you can personally work with me at brea Thank you so much once again and remember, knowledge is power.