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Proximal Hamstring Tendinopathy is a horrible condition affecting athletes and non-athletes alike. If you fall victim to the misguided information that is circulating the internet, symptoms can persist for months, sometimes years and start impacting your everyday life.
This podcast is for those looking for clear, evidence-based guidance to overcome Proximal Hamstring Tendinopathy. Hosted by Brodie Sharpe, an experienced physiotherapist and content creator, this podcast aims to provide you with the clarity & control you desperately need.
Each episode brings you one step closer to finally overcoming your proximal hamstring tendinopathy. With solo episodes by Brodie, success stories from past sufferers and professional interviews from physiotherapists, coaches, researchers and other health professionals so you get world class content.
Tune in from episode #1 to reap the full benefits and let's get your rehabilitation back on track!
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On today's episode, what modern science reveals about tendon pain and recovery. Welcome to the podcast that gives you the most up to date evidence based information on PHT rehab. My name is Brodie. I am an online physio, but I've also managed to overcome my own battle with PHT in the past. And now I've made it my mission to give you all the resources you need to overcome this condition yourself. So with that, let's dive into today's episode. Welcome back everyone, we are going to be reviewing a recently released uh article about where we're at in terms of understanding tendon pathology and ways we can influence its recovery. We're taking a deep dive into not only the pathophysiology from a, I guess, physical mechanical standpoint, but also a few other directions in more of a holistic sense of what the tendon shows. uh If you are interested in My high rocks race that was last weekend. Um, I will be doing a full kind of recap on the run smarter podcast. It will be released next week. Uh, I only say this because I know I've been sort of building up what my PhD recovery has looked like over the past couple of months in preparation for the race. So if you've been following that and being like, I wonder how he goes. Um, I decided to put that into the run smarter podcast as I ponder upon my yearly reflections, a good time to look at reflections. so since the race has just been completed, plenty of things for me to reflect on and decide to do a complete episode on that. So go check that out or wait for its release uh if you are interested. However, let's dive into this paper. The title is exploring molecular and cellular signaling pathways, unraveling the pathogenesis of tendinopathy. It's a lot. And in fact, this paper is quite scientifically, jargon heavy, I guess you could say, I've tried my best to sort of boil it down into kind of simple terms that I can understand as well as you can also understand because even though I have my background in physiotherapy, a lot of this in terms of its oxidative stress and signaling pathways and just the chemicals and the bonds and all those sorts of things really someone goes over my head since it's been a long time since I've looked at biology. uh But I think the general message of what this paper reveals is actually really, really insightful that something that you can relate to and my practice and managing my own tendencies as well as managing my clients uh comes across a few revolutionary game changes. And so this is unraveling the pathogenesis or like the disease part of tendinopathies. And so let's dive in, I'm going to be going through the background of what's included in some of the sections in the background, as well as then just breaking down into certain sections, they talk about what happens in terms of structure of a normal healthy tendon, then what happens in the various pathways once it becomes overloaded or starts to undergo some sort of pathological state. And then it starts to look at ways of what's some emerging treatments that hasn't really been considered yet. And yeah, hopefully give you a better understanding, a better holistic approach as to not just loading, not just doing the right exercises, but other things you can do to help give you the best chance for success. Okay, so it starts off by saying, tendon disorders encompass a spectrum of conditions from traumatic injuries to chronic degenerative diseases such as tendinopathies. Clinically, such alterations present as a constellation of symptoms, including pain, swelling, and a decline in functional capacity. The development of tendinopathy can be broadly attributed to intrinsic and extrinsic factors. The intrinsic factors encompass a spectrum of conditions such as systemic disease, family predispositions, advancing age, in neuromuscular control, irregular joint mobility, muscular weakness, and structural alterations within the tendon itself. The extrinsic factors are environmental and activity related, including overuse injuries, improper intensity of activity, inadequate recovery periods, and poor workplace ergonomics. This is talking about, you know, lower limb and upper limb tendinopathies. In the workplace, a lot of, say, rotator cuff or shoulder tendinopathies, a lot of like tennis elbow or like elbow tendinopathies. And so that's where some of these things come in play when talking about workplace and ergonomics and how people move through space. But the extrinsic factors are a lot about what we talk about in the podcast. It is the balance between what you put your body through, the overload or adequate load, but also the recovery aspect. It's a fine balance between load and recovery. If you load yourself really hard, you better make sure you recover really hard. But if there's ever a tip of the scale where your training surpasses your ability to recover, then that's when those intrinsic factors can get out of whack and increase your risk of a tendinopathy. But then you also have these underlying intrinsic factors that could be at your advantage or disadvantage. We're talking about age, obviously being one of them and Some people have hypermobile joints. And so that puts the tendons themselves at a bit of a disadvantage. We're talking about systemic disease. I'm gonna talk about that in a little bit more detail later in this article. The paper continues, patients with tendinopathies are generally older than the general population. The population aged between 45 and 64 are the greatest affected. However, tendinopathies can also occur at earlier age. In addition, due to the occupational demands, specific populations who perform repetitive activities more often, more intensely, and for a longer time face higher incidences of tendinopathy. For example, the incidence of a mid-portion Achilles tendinopathy in a general population is 1.85 per 1,000 people. This is lower than the incidence of military population who is close to three per 1,000. and the annual incidence of seven and 9 % of top level runners. So just right about why I was saying the more you load the Achilles, more the demands or your occupation or your tasks or what activities you're interested in. If it applies more load on the Achilles, you're more likely to get an Achilles tendinopathy. Multiple management strategies, including surgical repairs, pain management, various physical therapies, loading programs, etc. have been recommended for treatments for patients with tendinopathy. This is a shared the shared goal of this rehab is to reduce symptoms, in particular, reduce pain, promote tendon healing and improve patient function. The outcomes are not always satisfactory and are correlated with inferior repair capacity of the tendon and poor understanding of the pathological changes. Therefore reviewing in depth studies of these molecular mechanisms is necessary in understanding the pathogenesis of tendinopathy and in identifying the methods for clinical management. And so the next two sections are titled the molecular composition of healthy tendons talking about how a tendon is actually structured. And then we dive into section three, which is the macroscopic and microscopic observations of tendinopathy. So I'm going to kind of piece those together. And so let's start off with section two, what a healthy tendon is actually made of, not necessarily a tendinopathy, but the tendon, the healthy tendon itself. So a tendon is, it's got like a rope like structure that connects to the bone. Obviously muscle converts into tendon, which then converts or attaches itself onto the bone. That's how the force is transferred. That's how we get our skeleton to move. So for example, like in your calf muscle, we have the calf that then slowly becomes or forms into the Achilles that then attaches to the heel bone. So you can push off the ground and move through space. So tendons are built like, uh kind of like cables, rather than being like one solid piece of material, the tendons made up of like multiple layers within layers within layers. So they have small collagen fibers that twist together. And then those fibers, bundle into larger strands and then those strands bundle into larger, again, sort of thick cables. So we have small fibers twisted together that then bundle together those bundles bundled into bigger bundles which bundle into bigger bundles. And so this layered design makes tendons strong, flexible and resilient much like a uh climbing rope rather than a piece of string. So between these bundles are also softer tissue. And these softer tissues allow the bundles to slide smoothly between one another. It contains blood vessels and nerves within the tendon itself. And this helps the tendon cope with repeated loading during activities like running. And so what are these bundles fibers made of? Most of it is made of collagen, mostly type one collagen if we wanna be really specific. This makes up a vast majority of the tendon and gives it its strength. So think of the collagen as like the steel wires inside a cable. There's also some elastin in small portions. So elastin allows for the tendon to stretch slightly and recoil slightly, important for storing and releasing energy when you run. And then they have uh what they call proteoglycans and water. And these help keep the tendons hydrated and allow for nutrients and those nutrients to move through the tissue. So the paper also talks about cells that sort of maintain tendon health. They talk about tenocytes and tendon stem cells and immune cells that kind of remain a bit quiet within until called upon, but they exist within the tendon itself. But I'm happy just to skip through that bit. Let's talk about section three, what actually changes inside the tendon with a tendinopathy. So tendinopathy doesn't affect every part of the tendon equally. In fact, most tendinopathy only affect like a very small portion of a tendon. despite how much pain you're in and how long you've had it for, like in the most, I guess, kind of severe cases, I would say about 50 % of the tendon is actually undergoing a tendinopathy. For most cases, even if it's chronic and really debilitating, we're probably talking about 10%, 20 % of the tendon itself. That's leaving 70, 80 % of the rest of the tendon just being very, very healthy portions of the tendon. So, Tendonopathy doesn't affect every part of the tendon equally. It mostly shows up near the tendon as it attaches to the bone. This is an insertional tendinopathy. This is what most often proximal hamstring tendinopathy is. It's categorized as an insertional tendinopathy. So as it attaches to the bone, we also have insertional Achilles tendinopathy as the lesser common of the Achilles tendinopathy. But the other more classic, more common. Achilles tendinopathy is a mid portion Achilles tendinopathy. So most tendinopathy can be categorized as either mid portion or insertional. These are just higher stress, um higher strain areas, so more likely to develop in that section of the tendon. So what tendon what does a tendinopathy look like to a naked eye when they scan a tendon? What does it actually look like in a healthy tendon? collagen fibers are neatly aligned in a wave like pattern that help absorb load. but in a tendinopathy, the collagen fibers lose their tidy alignment. The tissue becomes more disorganized and weaker. The tendon may be thickened or stiffened and develop areas of degeneration. When I had Keith Barr on the podcast, he used the terminology of becoming a bit screwed up. The fibers themselves, they're no longer aligned, they're a little bit screwed up, only in the certain portion of the tendon that has the tendinopathy. The other healthy portions will be nice and aligned, able to absorb load effectively. Sometimes calcium deposits or cartilage like tissue appear. So if someone has had a scan, they may show signs of tendinopathy plus or minus they may comment on some calcium deposits. And this is typically near the bone attachment. But that's with the naked eye or, you know, close in eye what happens under the microscope with these tendons undergo tendipathy. When scientists zoom in, they see that the tendonopathy it's not just wear and tear these collagen fibers become thinner and less organized. The tendon structure becomes more gel like due to excessive water binding molecules. So there's just more fluid within the tendon. This is probably why it does look quite thickened. And as Keith Barr suggested, why some people can have an analgesic effect to load. So if you are loading up your proximal hamstring tendon when it's sore or like mildly sore to do so, say like a double leg long lever bridge, but then those symptoms dissipate as you hold that load. And then as you get up and walk around, it actually feels a lot better. That analgesic effect, what Keith Barr said seems to be like you're wringing out that gel like fluid or the water content that's within the tendon itself. If you apply load, it sort of rings out that fluid and circulates it throughout the body. And then if there's less fluid in that tendon, there's less kind of mechanical pressure, which can elicit pain signals, which is why perhaps you do start feeling better afterwards. And why that those symptoms may return several hours later because the water content seeps back in. Again, under the microscope, under the microscope they have uh cells, they change their shape and behave differently. We have new blood cells and nerves that grow in the areas, which is something I've touched on the podcast before briefly. But with a tendinopathy, sometimes there can be more blood vessels that do emerge within and around the tendon, but also nerves. We've seen some research published that show that more nerves will proliferate around the tendon but also go deeper into the tendon. Some tendons have nerves, but it seems like more nerves do generate and also into deeper layers of the tendon, which is maybe one reason and explain why during a tendinopathy pain, can become more painful and really sensitive uh despite low loads. uh Potentially one of the reasons why a flare up might last quite a long time and pain levels be quite high. And while you might see, say for a scan, if someone shows like a very mild tendinopathy, yet they're in an eight out of 10 pain all day, every day, the scan level of damage or severity of what they found doesn't necessarily reflect what the pain experience is for people. It's because maybe there's a few other reasons, but potentially in one of these cases, there may be more nerves around the tendon. embedded a bit deeper into the tendon just makes the overall uh area more sensitive. So they also comment on this paper that importantly, traditional inflammation sort of like what you see with a swollen ankle where everything blows up. It's not uh often that obvious, but at a molecular level, inflammatory signals are still active and just a bit more subtle and more long lasting. So this why we moved away from the term tendonitis, itis meaning inflammation, uh and using now the more accepted term of tendinopathy, meaning pathology of the tendon, because yes, it's not like a traditional inflammation that's the primary driver of the pain and dysfunction, but this paper does clearly show that there is some sort of inflammatory signals and pathways that are going on. It's just a lot more subtle and long lasting. The paper also talks about the tendon pain continuum, which is similar to Jill Cook's work, which I've talked about before, as a tendinopathy is kind of on a spectrum. It starts off as a reactive tendinopathy. So this is where the tendon thickens slightly to protect itself. It's in its early warning stages, but with load reduction or like smart training, trying to be careful with, I guess, optimizing your load management. the tendon can fully recover. Then it undergoes this tendon. Well, if continues to mismanage the load, the tendon can enter this disrepair phase. So the structure starts to break down, collagen becomes disorganized. Some healing is still possible with the right loading strategy. But again, if ignored, and we're talking about continue to be ignored over months and months and months, it can get to this degenerative stage where there is significant structural damage. There is poor quality collagen that replaces strong collagen. So it's, I guess, less efficient to absorb load and behave as a tendon. It's got limited healing capacity and the pain may fluctuate. And this is where the tendon is structurally compromised. The one different thing that's emerging is like in that Jill Cook paper, which is, you know, decades old now, ah is that the further you go down this continuum from reactive to disrepair to degenerative, it suggests that it becomes harder and harder to revert back to a healthy tendon. And if it gets degenerative, the case would be said for, uh now we're not looking at the possibility of it returning back to a fully healthy tendon. Our priority is now to decrease your pain, obviously get back to full function and symptom free, but there's always gonna be a degenerative portion in that tendon. Our goal is to focus on the healthy portions that still remain within that tendon, getting you super fit, super strong through those healthy portions. However, emerging evidence again, I'm going to talk about Keith Barr has shown in his studies that if you take advantage and the knowledge of stress shielding and a few of his other protocols around maybe some vitamin C and collagen around your workouts, he has shown that even the most degenerative tendons can convert back to normal healthy tendons. proof, that being just with some case studies here and there and his results in the lab show that yes, you can convert degenerative chronic tendinopathy is back to normal healthy tendons, it just needs to be done the right way. It's tough to do but can be still be done. So there's definitely hope in the in the emerging research. So why this matters for you like a tendinopathy isn't just a sore tendon, it's a change in the tissue quality, the load that was once tolerated can become too much can become threatening. Recovery does take longer. And simply just pushing through training often makes things worse, but also at the same time, complete rest doesn't fix the problem either. So effective rehab works by matching load to the tendons capacity. This is what we talk about in the podcast all the time. Just allowing the cells to rebuild healthier tissue over time. So now we have an understanding of what the tendon, a healthy tendon is made of. And when it comes to a tendinopathy, what it looks like from the naked eye to the microscopic level. It now does into the sections talking about molecular pathogenesis of the tendon and what pathways are going on. I think there's four, one, two, three, four, five. Five sections talking about ways and pathways that tendons can become more pathological. So. I've learned a few things reading this paper. So let's dive into them now. The first one is the obvious one of what's leading the tendinopathy, what's leading the pathogenesis of the tendinopathy and that is mechanical loading. So when load becomes a problem, so tendons need load to stay healthy, but too much, too often or too little can cause problems. We want that optimal loading. If you completely offload your tendons, if you... break your ankle and you have to put your ankle in a cast and crutches and wheelchair for several weeks. Tendons aren't going to like that at all. It does need load to stay healthy, but obviously too much load and that's not healthy either. So we need healthy loading. When you run and when your strength trained appropriately, your tendon cells sense the load. It increases collagen production. The tendon becomes stronger and more resilient. I talk about this process called collagen synthesis. It is the breakdown and buildup of collagen, which as we talked about before, most of the tendon, about 80 % of the tendon structure is made up of collagen. So we need that buildup and breakdown of healthy collagen for the tendons to stay healthy. But when the load goes wrong, problems will arise if your load, if you spike your loads too quickly, sudden mileage, hills, speed, maybe a change in shoes. Just, we know these things can influence tendon load. or if your recovery is insufficient. So if you're doing back to back runs, back to back to back runs, if you have less sleep, if your sleep quality is poor, if your nutrition is poor, this inhibits your ability to recover, which inhibits your collagen synthesis breakdown and build up of collagen. So the breakdown kind of breaks down during your workouts, which can be necessary, but the build up requires the adequate recovery afterwards. That's where the nutrients, the protein, the maybe collagen supplements, maybe, well, definitely sleep, all those things help the buildup process. So that needs to be optimal. So this is why when we have a tendinopathy, we see that rest alone doesn't solve the problem and progressive loading is essential. But the timing and the dosage matter, the right exercises, we need the right recovery. We just need to try to find where your current sweet spot is. foster that adapt to that that could still be running that could still be cycling or strength training that could be doing the right strength exercises we just need to find where that optimal load is so that we can start triggering this collagen synthesis again and get it um into your advantage. So mechanical loading is one pathway that they talk about. The other pathway they talk about is inflammation. And this isn't just classic the classic swelling that you expect but uh The tendinopathy isn't inflamed like an ankle sprain, but inflammation plays a role behind the scenes. In many chronic tendinopathies, you don't see redness or swelling. There's some anti-inflammatory treatments do sometimes help, but only temporarily. But at a molecular level, we have tendon cells, they release inflammatory signals. We have immune cells that are quietly activated. We have chemical messengers that stay switched on for a very long time. And this creates a low grade persistent inflammatory environment, which means that your pain pathways become more sensitized. We have the healing process is interfered. And this also encourages some abnormal tissue changes. So like we say, the aligned well aligned fibers of the tendons start to become a bit more disorganized. So some of these chemicals are also linked to pain signaling, which helps explain why pain doesn't always match what you find on scans and that the tendons can hurt even when structurally it's not that bad. So you could go for a walk. It doesn't really make mechanical sense and be overloaded from a walk, but it could still hurt afterwards just because that pain signaling pathway, that inflammatory low grade chronic inflammatory environment. uh just starts to manifest those symptoms. So we've got mechanical load, we've got inflammation is another driver. The other one that they talk about is oxidative stress. And so the key idea here is like hard training produces metabolic exhaust fumes inside the cells, it's just like byproduct. And when recovery can't keep up, those byproducts start causing damage, start causing damage to the cells. This is called oxidative stress. So in tendons, Excessive oxidative stress causes a bunch of things. We're talking about excessive oxidative stress. So too much. It damages tendon cells, it disrupts collagen structure, it activates enzymes that break down tissue and it increases cell death. This is most likely when your training is just way too high or like I mentioned before, recovery or sleep or nutrition is inadequate or really poor. Your blood sugar control is impaired. We'll talk about that in a second. excessive oxidative stress uh can become a vicious cycle because the stress can lead to inflammation, the inflammation can lead to more stress. And so we've got this oxidative stress, inflammatory uh feed forward loop that can continue. And that can just slow down the healing essentially, but also increase the pain, which then, you know, has a whole bunch of other components. Okay, they also talk about this process called senescence, which something I've heard here and there, but haven't really quite understood, but allow me to sort of break it down for you. So the senescence is kind of like the cells within the tendon start aging. So tendon cell aging is also senescence. And this is why tendons struggle more over time. And as tendon cells age and become chronically stressed, they enter a state where they stop repairing the tissue properly. And these are senescent cells, they produce inflammatory chemicals, they release enzymes that degrade the collagen within the tendon, they respond poorly to loading, they accumulate over time, these senescent cells just accumulate, accumulate, accumulate, making it harder to adapt to training, making it more likely to start becoming inflammatory. So this helps explain why tendinopathy can become more common with age, and it takes longer. to heal, we're in chronic cases and also with age takes longer for tendons to heal. We also have the long standing tendon pain is also harder to reverse. So importantly, aging isn't just about the years that you've lived, but it's also about how much training you've accumulated over the years and years and decades and any previous injuries, any poor training habits, all of these things are factored into how your ability to recover your ability to bounce back. uh Then this is the main one that I want to talk about. And they talk in this paper about metabolic health. So I had to look up the definition of this. So metabolic health is your body's ability to efficiently process food into energy, maintain stable blood sugar, manage fats, and keep hormones balanced, marked by healthy levels of blood sugar, glucose, cholesterol, triglycerides and waist circumference. So I've seen some very strong and healthy people that run marathons and look like, you know, they're uh BMI very healthy, yet they can, they've got very, very poor control of their blood glucose. They may be pre-diabetic. I've seen a lot of athletes become pre-diabetic just because they consume excessive amount of carbs or processed sugars or processed foods and all those sorts of things and their glucose really spikes, they really struggle to maintain those glucose levels and blood sugar levels and this really inhibits their metabolic health. Diabetes would be one of the big factors showing that you have a problem with your metabolic health. And so, Again, sort of getting outside the realm of physiotherapy, but just thought I'd try to set the stage here because this paper does talk about metabolic health and how the tendons environment changes based on your own metabolic health. And this is why the holistic approach is really important. So tendons are affected by whole body health, not just your training. Research shows that higher tendinopathy, there is a higher tendinopathy risk with poor blood sugar control, diabetes, high cholesterol and metabolic dysfunction. In these states, the tendon cell struggles to produce high quality collagen. Also the repair processes are disrupted. The cells are pushed toward bone-like and fatty tissue instead of the tendon tissue. This helps explain why some runners develop tendon pain despite reasonable training loads. It can just appear out of nowhere and tendons can appear without a clear overload trigger. Because like we say, the internal environment is pushing the body to uh more of a 10, develop more of a tendinopathy or a risk of a tendinopathy. So as well, we're talking about big picture, the tendinopathy isn't just caused by one thing could be load management, could be persistent low grade inflammation could be an accumulation of cellular stress, could be its reduced healing capacity or could just be a whole body health influence. And so maybe you're listening to this podcast and kind of self reflecting how am I in these particular realms? Cause that can be particularly important. One thing that I think this paper is missing, which kind of doesn't necessarily cover the topic that they were wanting to cover, but ah chronic pain and the influence of the brain and the nervous system is definitely something that is missing from this paper. If we're talking about whole holistic stuff, we know that pain, we know that fear, anxieties, catastrophization, hypervigilance, just general stress like emotional stress, all these things really influence how someone perceives pain and how the nervous system can be really wired up that uh sympathetic drive if someone has a very high sympathetic drive, they are going to experience really amplified levels of pain that doesn't necessarily reflect the level of damage. And when it comes to recovery, if someone is really influenced if their pain is really influenced by their emotional state. They are very hindered in their ability to fully recover if the emotional component isn't addressed. For example, with proximal hamstring tendinopathy, a lot of people struggle to return to sitting symptom free. But whenever they sit, even if they start sitting symptom free, they're really worked up, they're really anxious, they're really hypervigilance, so they sit down, they think, where's my pain, where's my pain, where's my pain, what's the pain like out of 10? Oh, there's my pain, oh my God, I have to sit down in this meeting for two hours, I don't think I can make it, my pain's increasing, yes, my pain is definitely increasing, oh my God, what can I do, the surface I'm sitting on is too firm, I knew I should have brought my cushion, how am I ever gonna get over this, will I ever sit in a meeting again, symptom free? Obviously, this is an extreme example, but you can see how paying attention to these symptoms, can really work up the brain and really kind of wire the connection between sitting and pain, pain and sitting. And that becomes really hard to unravel unless you address the component emotionally. You can't simply just do your strength exercises, encourage more tendon tolerance, increase the amount of compression of the tendon to tolerate more compression and then sit and expect to have success if we haven't yet calmed down the nervous system. unwound your thought process. Because if you're thinking about it, the pain is going to come. Another example that I often see are runners who really are hyper vigilant about their pain levels when they go for a run. Every step that they take, how's my pain? How's my pain? Where's my pain? Brody says it should be less than a four out of 10. So I'm going to focus on it every single step to make sure that stays below a four out of 10. What's it now? Is it a two? Okay, it's climbing up to a three. Like that hyper vigilance. ah can be the sense of afterwards, you're just in a lot of pain because you have been thinking about that pain for a long, long, long time. And your brain has had no choice but to prioritize it and think, this is a big deal. This is very serious. This is a big threat because you're so much attention to it. Therefore, I'm going to deliver a lot of pain. And not only that, but I'm going to wire these connections together between running and pain, pain and running. And when done over several weeks, several months, they become ingrained. that can be very hard to unpack. so, yeah, then like on the opposite side, that same person can go for a run where they're calling a friend or they're running with a friend and they're gossiping and having fun and laughing and having a great time talking to one another. And you're completely distracted away from the pain. And you can do the same run the same distance the same speed. But on the back of that pain levels be really low, in fact, or symptom free. And so mechanically, the changes in pain response make no sense whatsoever. But from a attention standpoint, make a lot of sense. And so this isn't just to do with tendons, this is to do with all injuries. But it's something that I think is kind of missing in this entire paper to talk about, okay, the nervous system, the sympathetic to parasympathetic. attention, hypervigilance, the anxieties and all those sorts of things that encompass it. uh Obviously, we're moving away. This is like looking at uh molecular pathways and processes that influence pain and the tissues within the tendon. So I guess that's outside of that. But if we're covering a topic or a podcast episode on this, I think I thought it was worth mentioning. This paper does also talk about future directions ah for treatments and what are some new treatments that are out there. It does only briefly touch on this because it's not what the entire paper is about, but it's just that next stepping stone of, okay, these are our new understandings and mechanisms and pathways of tendon pathology. Where does this take us in the direction of treatments? And so this paper does talk about a better diagnosis. So beyond just looking at a tendon, looking how thick it is on ultrasound and then making a diagnosis. So current imaging just shows structure doesn't tell us much about the healing potential, but a future direction, the future approaches aim to detect early cellular changes, identify harmful biological environments. So we're talking about those metabolic issues or inflammatory this low grade inflammatory environment and track tendon adaptation, not just damage. So this could help catch tendinopathy earlier, prioritize rehab guidelines. avoid unnecessary surgery and those sorts of things. For a runner, key takeaway like in the future treatment decisions may be guided by biology, not just pain and scans. They also talk about multi target treatments. So not just like a one magic fix, but looking at tendinopathy treatment paths that encompass load, inflammation, oxidative stress, factor in the aging process, but also factor in metabolism. And so this addresses multiple systems at once and can be a really good way of I guess, healing the tendon from all directions. This reinforces why exercise alone sometimes just stalls your progress. Injections alone are really solve the problem. Rehab must consider the whole person, this holistic approach. They briefly mentioned medications, so um can have some benefits just with caveats. So Some medications show promise at a cellular level. So certain anti-inflammation medications may reduce harmful signaling and some others may protect cell, tendon cells from aging. However, some commonly used injections may impair long-term tendon health. They have short-term pain relief only, doesn't really necessarily affect an equal tissue healing. But they also talk about this future direction being regenerative and stem cell approaches. ah It's exciting research says this paper says the authors is exciting but early. So research is exploring tendon cell, tendon stem cells, stem cell injections, cell derived vesicles. They're looking at biological scaffolds that mimic tendon structure. These approaches aim to improve collagen organization, reduce scar tissue, restore tendon like properties. But currently most of the evidence is in and animal studies, the human results are still very, limited. And the cost and regulation remains a bit of a barrier. They also talk about the gene level and molecular therapies. scientists are investigating micro RNA that control inflammation and healing sort of ways to switch off harmful tendon signals, and also methods to restore healthier cell behavior. So this is cutting edge research, but it's not clinical practice as yet. And so that's what they mentioned this paper, let's go through the conclusions of this paper. They say tendinopathy is a complex and multifactorial disease that affects tendon structure and function. The molecular mechanisms underlying this pathogenesis involves intricate interactions between mechanical stress, inflammation, oxidative stress, metabolic disorders, and so on. A personalized approach to treatment considering individual patient factors such as age, activity level, and comorbidities. Although current clinical treatments provide symptomatic relief, they have shown limited success in fully restoring the tendon function. The efficacy of these treatments is still inconsistent, presenting a challenge in identifying universal effective treatments. A deeper understanding of the molecular pathways involved in tendinopathy will inform the development of targeted treatments to improve our ability to predict and prevent its onset. New and innovative treatments like gene therapy and epigenetic modulation are paving the way for targeted interventions in tendon degeneration and repair by focusing on specific molecular pathways. By leveraging this knowledge, the scientific community can work towards innovative therapies coupled by rigorous clinical validation to address the root cause of tendinopathy ultimately improving patient outcomes and reducing the socioeconomic burden of this prevalent musculoskeletal disorder. So this is, like I say, cutting edge, holistic, uh maybe a few things that you haven't heard of, and can help target and redirect or add on extra components to your tendon rehab. Or even if you don't have a tendon opathy, some adjustments you can make in your general lifestyle to reduce your risk of a tendinopathy. I think it highlights a lot of key important stuff that I don't usually find in a lot of tendinopathy papers. So I'll continue to keep my eye on any other papers like this that emerge in the future like as a emerging research, it's a long way to go and a lot of exciting directions. If they are released, you'll be the first to hear it on this podcast. So I hope you enjoyed and we'll catch you in the next episode. If you are looking for more PhD resources, then check out my website link in the show notes. uh There you will find my free PHT 5-day course, other online content and ways you can personally connect with me, including a free 20-minute injury chat to discuss your current rehab and any tweaks you might need to make. Well done for taking an active role in your rehab by listening to content like this and together we can start ticking off all of your rehab goals and finally overcome your PHT.