This interview Brodie chats with advanced practice physio, sonographer & shockwave specialist Benoy Mathew. Shockwave therapy is a treatment method administered by therapists and Benoy answers all our questions on this treatment option. Firstly, Benoy helps answer the question of what Shockwave is and what the clinic experience looks like for a patient. Secondly, we help decipher the confusion of who will benefit most from shockwave therapy. Benoy explains which running conditions will respond favorably and which conditions will be ineffective. Also, which characteristics create a suitable candidate for shockwave therapy. Lastly, we answer all your social media questions and delve into specific running conditions such as patellar pain, plantar fasciitis and proximal hamstring tendinopathy. Click here to find Benoy Mathew on Twitter For Benoy's online shockwave course head to https://study.physiotutors.com/course/running-rehab/ Click here to find the Run Smarter App on IOS or Android You can also support the podcast for $5AUD per month and interact with the podcast on a deeper level by visiting our patreon page You can also click here for our smarter runner facebook group
Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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on today's episode, part two of our shockwave discussion with Benoit Matthew. 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, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers and met with bad advice conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp, I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. Really had a part two episode before so don't really know what to say here. We welcome back Benoit Matthew because our interview went for an hour and 15 minutes and decided to break it up into two parts and you'll already be familiar with Benoit. In part two we delve into answering your questions and delving into shockwave more specifically around conditions and so I hope you enjoy it. We sort of, We sort of had an abrupt finish to. part one because I just split into two and just put into two episodes. And so we dive straight back in. So here is Benoy Matthew. I did propose this interview to the patrons of the podcast and if they had any questions and Jill asks specifically around plantar fasciitis. I think we covered a lot of this. She asked, is it effective? You've mentioned. Yes. Is it painful? Yes. Are there any precautions like post therapy and can she asks, can I exercise afterwards? Okay, that's a great point is with runners. The key thing with this is we have to be very clear with their advice with runners because when the pain is less, they're more likely to overdo it. So let's assume that as a runner, she has done the whole package, you know, good footwear advice, you know, not running on barefoot or a loading program like wrath lift loading program. She's having all those things. So, so my key advice would be is generally, let's, let's put the rehab into two phases. So let's imagine that she's getting three sessions of shockwave. Let's look at that three weeks and let's look the 12 weeks after. So I always try to separate that two segments. So let's look at the first segment when she's having treatment. So in the first segment, depends on irritability. For example, if it's very, there's a common question I'm asked is, do I stop people running during that three weeks or sometimes? So the answer is, For me, it depends on the irritability. So if you get a runner who gets pain only after 40 minutes of running, there is no need for me to stop her from running. So I might ask her to continue running with 20, 25 minutes. But generally, I advise her not to run for 48 hours. So suppose she had treatment on Monday, I would suggest her not to run Monday and Tuesday. And during that whole three, four weeks, I generally stop any speed work. Speed work irritates plantar fasciitis, no speed work. and try to have a bit of appropriate shoes. If you go for more minimalistic shoes, it put more strain. So generally, I advise her to have that cushion, like either heel inserts or something to reduce the cushioning, and then to stop the speed work during that session, and then start the loading. And then once she finishes the course of Shockwave, that three weeks, then I start pushing her really hard. So I don't really push people hard. while I'm giving shockwave because your body is trying to remodel. It doesn't make any sense trying to push and remodel at the same time. And anyway, it's only three weeks. So they might still continue, you know, two days of running, but they may not be doing a lot of speed work and a lot of plyometrics. I totally stop all plyometrics during that three weeks. So no speed work, no plyometrics, you know, try to keep the symptoms without flaring up. And once you've completed the course, anyway, you've got 12 weeks anyway after that. So there's no need to rush because you're going to slowly push that tissue remodeling. and to start the rehab and all this sort of work. So you need to put that into two phases, during the shockwave phase and post shockwave phase, and both are equally important. And I'm glad that those expectations are laid down as well, that in these first three weeks, we're gonna have to back off a lot of the mileage and speed in that work. Would you say that applies to other tendons? So the Achilles, the patellar tendon, and the proximal hamstring? Yeah, so the main thing is a high impact work. So for example, you know, runners want exercise, which is so even they can go on the same day to the gym and do a bit of bike work, a bit of cross trainer, a bit of machines, you know, a bit of full work, totally fine, you know, but anything which is high impact and because, you know, tendons are quite sensitive to speed and high impact. So I advise not to do like aggressive sort of loading during that phase where they are remodeling and trying to create those physiological changes. So, and the question of. People always want a black and white yes or no answer, like whether I should run or not. It pretty much based on the two factors I would say is irritability of the symptoms and how much they can run without pain. So if you've got an atlantic patient or a patholitanum patient who can run 50 minutes, 60 minutes, there's absolutely no reason to stop them running. On the other side, you've got somebody with plantar fasciitis who's hobbling in the morning, it takes them 40 minutes to settle down. It makes no sense to continue running and shock at the same time. So... For me, I think the irritability of the symptoms, especially the morning or 24 hours after, and how much can run is the two factors. So in some patients, I'll totally stop running during the three weeks, but in many patients, I'll still keep them running with some modification. So reducing the distance, totally stopping the speed work and the plyometrics for that three weeks, and then gradually introduce them later. Because that's one of the main problems of giving shockwave before an event, because you don't have time for that. So if you've got a marathon coming or half marathon coming in four weeks, you don't have time for all those things because you're trying to, you can't stop all those things. So, so many runners, when they come to me, I say to them, come back to me once you're finished the even. And when you can give me 12 weeks, when you can give me time, come back to me and then we can do shockwave. Right now is not the time. So you try to plan your treatment so that when you can really get a more long-term response rather than a quick fix, which generally always disappoints everyone. Yeah. And it does seem like it is a patient process and a lot of runners don't really have or want the patients and it does seem that the, the exercise or guidance that you're giving within those three weeks are just based on clinical justification, based on the nature of the symptoms and based on the person, what their level of capacity currently is like, what their strength is currently like, what their running capacity is currently like, and just using your the exercise requirements within those three weeks? Yeah, I think with runners is we always want to keep them running even if you can let them run two days a week, they'll be very happy at least they're doing something. So 100% of patients, I will make some modification. It'll be a distance, it'll be a speed, it'll be some variables I'll say not to do. For example, in my proximal hamstring tendonopathy patients, I will strictly say not to do any hills or speed for at least six to eight weeks because it tends to flat up. So certain tenants are different. With the petal tendon, I would say not to do a lot of downhill running, you know, downhill makes a lot of strain on that. And the Achilles and foot, most foot and ankle, it generally speed work, speed work generally makes it irritate more. And, and especially if they made any transition to more minimalistic type of shoes where, you know, they're going into more loading as well. So obviously, you know, I might link up with the MSK podiatrist who can support on that journey as well. So I think, you know, we know that number one. treatment for runners is load management and education. There is no different whether you have shockwave or not. So we have to manage that appropriate load, educating them on the pain levels. So again, we don't want to be zero out of 10. They can still do stuff with three or four out of 10, but we don't want to flat up. We don't want that 24 hours for a response. So I think that's one of the reasons I like the person giving shockwave to also be managing the rehab. So in many centers, I see people go shockwave somewhere, they get the different advice. and they go to rehab, somebody else, they get a different advice, and then it's a bit of confusion for the therapist. So ideally, or if you're giving, they should have communication between the two professionals. So if somebody is giving a shockwave, they should know what the rehab person is doing at the same time, because otherwise the patient is going to get a bit of a different information and lead to aggravation because they might, some therapists will say, fine, you can do everything. And then the next day, next week you see them, they're in bad flat up because they just went and did like 15 minutes of plyometric or some speed work. And... and body, everything flaps up. So we need to have the continuity and clear message when we give shockwave and the rehab. So ideally you want the same person or if it's a different person, we need to communicate and make sure that we are not giving mixed message to the runner that you can do anything you want. Because the idea is we want to get them full function, but at the same time, we don't want to flare up. Because if you flare them up and make them worse, they're going to lose confidence in the treatment. They're going to say, okay, I had shockwave, it made me worse. I hear this quite a bit. They say, I had shockwave, it made me worse. What did the therapist tell you? No clear advice on the post-treatment advice. So if you're giving shock waves, very important to give a very clear advice on post-treatment, what to do, what not to do. Mostly for runners, it's telling them what not to do, which is equally important than telling them what to do. Because if you don't tell them clearly, they're going to overdo it. You can always assume that in runners. If you say, just listen to your body, they won't listen. They're just going to, because once they finish the treatment, they're going to feel less pain than they feel everything is cured. Because a lot of runners think they're cured. You don't cure a tendon in two sessions. You know, it takes time. So I don't play the expectation straight away and say, it's kickstarting the healing, it takes 12 weeks. Let's rebuild it. Now is the time not to overdo it. Let's build up slowly. We're looking at a more long-term option. So as long as we make it clear that it's not a quick fix, they're more likely to listen. So it's up to us to educate them on the long-term. Many runners are very disappointed when they hear me saying it takes three plus 12, which is like basically it's four months, isn't it? Three to four months. So it's a long time. People think you're going to have shockwave and in two weeks you're back running full capacity. And if you look on certain websites, that's the message which has been shown. And that's not the truth really, because you know, if you, if anybody can fix tendons in two weeks, they should get the Nobel prize. You know, that's the million. That's the million dollar question. Nobody can, you know, there's, that's the Holy grail in tendon rehab is this takes time. There's no You can't, one of the things is, you know, you can't speed up nature. There's nothing, you know, it takes time and whatever morality you might. So it's like, you know, when I, another silly example I say, like, you know, when I came last year, I think two years I came to teach in Australia, it's like, when I went there, you have two options going to Australia. You can either go to the business, you know, first class, or you can go into the normal economic class, but I still land up at the same time. But you know, I'm not going to go quicker just because I pay more money and go in the first class So that's exactly the same with shockwave when you have shockwave you feel less pain and you can load more quicker But the healing is exactly the same So we are doing any you know people deserve is saying like you heal faster with shockwave There's no physiology evidence. It does that You know, we we're making them appear quicker because they have less pain the timelines are exactly the same lines, you know The overall experience is better. So just the same as flying first class and flying economy. Yeah. Yeah, it feels nicer and you feel it's quicker. You slept well and you feel better, but you both of this landed at the same time. That's what exactly is. So a lot of times you see some adverts saying, oh, you feel better, you feel faster. That's basic physiology. You can't speed up nature really. It's like nine months of pregnancy. There are a few loss you can't break anything. It's the same. So as long as people accept that. But I think they're a bit disappointed on session one, but they're very thankful that you've been very honest in that and that it's going to be in the long term. And what I think this is, this is a really crucial point I find it's a bit strange, but I think one of the reason is people seem to, runners tend to buy rehab better when they have a gadget or something with it. So when you say 12 weeks of rehab, they don't buy it. When you say Shockwave plus 12 weeks of rehab, nearly all of them buy it. want the best effect. So I guess that's the same with surgery as well. A lot of times people follow rehab protocols best after injections or after surgery or after shockwave. When you put an external object, your adherence and your compliance is better. So I feel that's one of the reasons I find the shockwave helps my patients because patients seem to listen better when I say, okay, we're going to give shockwave, but then you're going to do 12 weeks of rehab. They say, okay, that's fine. You know, whereas if you say before, they don't seem to follow it. So I guess it's a buying tool. People buy. rehab better when you say you're going to give shockwave for the pain relief. So it's, you know, as a good therapist, one of the things I learned as you get more experience is you have to be a good salesman to your patients. You have to sell your rehab and sometimes having the shockwave helps to sell your rehab better. And they seem to follow, you know, because you can have the best rehab, but if they don't do it, you know, you're not going to get the results. So it's, it's one way of selling your rehab to them to make sure they do it. So for me, it's a simple tool to reduce the pain and then get that rehab back to the gym, back loading. back doing your plyometric drills and then back to what they will enjoy. So it's a good adjunct in a short-term journey. And it's a very quick, you know, if you're talking about three sessions, three minutes, it's nine minute treatment, isn't it? It's nothing. When you talk to somebody who's been suffering for one or two years, nine minutes of treatment is a very small price if it can help them to get them going, especially if they fail rehab. So as I mentioned very clearly before, you know, it's not good practice to give shockwave unless they have exhausted. a good 12 weeks of progressive loading program. Yeah. I think it's one of the challenges of the therapist is to try and change your language to increase adherence and compliance to the program as much as you can, if we can backpad with just a little bit and go back to these patron questions, because Justin asks again with plantar fasciitis, if the heel bursa is involved, does it respond just as well? No, no, unfortunately with any bursa, for example, If you're dealing with insertion of the lacunus, if you have retrocalculal bursa, but any fluid collection doesn't do well with the shockwave because it gets dissipated when energy gets. So if you've got somebody with a fat-pad impingement, if you've got somebody with pre-petalobarcytes, the common question people ask is trochanteric bursitis. It works, keep it simple, it only works on tendons and muscles. So any fluid collection is not a good option to give a shockwave. Again, we need to know why they're getting fluid. and things like that. So if your ultrasound or report comes back saying it's got retrocalcinoid bursitis, then shockwave might not be the option. So, you know, again, so I was bashing up on steroid injection a few minutes ago, but again, you know, nothing is black and white. So one condition where steroid works really well is in retrocalcinoid bursa done under ultrasound guidance injection. So if you've got a small collection of fluid, which is inflamed, So you can put a bit of steroid within, as I said, steroid is bad within the tendon. But if you've got some bursitis around it, I don't see any harm in putting a little bit of a ultrasound guided injection into the bursa to reduce the inflammation. So again, you know, it's not black and white saying all story is bad. If you've got a localized bursitis, shockwave is just going to irritate it. But maybe if you've tried everything else, you've taken anti-inflammatory, you know, all that, there might be a role. by discussion with the sports doctors or orthopedic surgeon where they might do guided stuff for the bursa things. So the answer to your question is any bursitis, it's not an indication for shockwave. Yeah, and all those who don't have that medical background, that bursa is just like that fluid-filled sac for lubrication. That is not part of the tendon at all. It's not part of the structure. So when we say that injections... have the potential to do damage to a tendon if injected straight into the tendon. If there is a bursar involved, we're injecting into the bursar, which isn't a part of the tendon at all. So that can still be quite safe and still be quite effective. Yeah. And again, more and more, we are going more into guided injection. So if you want to be accurate, it makes sense. You go to somebody who is knowledgeable in, in providing ultrasound guided injection, so you know exactly that you're not sticking the needle into the tendon, but putting it right into the, into the bursar. where you really use your minim, you minimize your risk of complications. Yeah. So they, they're using the ultrasound as well at the same time, they're doing the injection so they can see on the screen, okay, the needle's going into the bursa now, and then they inject what they need to inject rather than just using blind faith and just saying, okay, here's the bursa and, um, just using their eyes just to, um, hopefully hit the bursa. The last question I have or the last topic I want to delve into, I see a lot of people with proximal hamstring tendinopathy and they are ones that get very chronic, very debilitating. A lot of the runners are very desperate and they, they want clarity. They want control. What can we do? You've said that proximal hamstring tendinopathy can be effective. Well, shockwave can be effective. Is there any considerations we can do in that three week phase or are there any, proximal hamstring tendinopathy specific instructions that you can have for people to increase the effectiveness? Yeah, so I think proximal hamstring is quite a funny area because it's quite deep, you know, quite, you know, hard to get in. So some practical point of view is it's quite an awkward treatment to give when you give on that. So I always have a chaperone when, if I'm treating a patient, because you have to get straight into the sitting bone. and I normally bring them to the edge of the table so that open up the space because it's pretty much medial to the sitting bone. Now the few considerations, so a small group, I would say quite a significant group of patients with proximal hamstring also get a bit of irritation of the nerve as well. So if you've got somebody who have a bit of sciatic nerve type of irritation, from my experience, they don't seem to respond with shockwave. Anything with nerve don't seem to do well. So if you've got somebody who's complaining of a bit of pins and needles, bit of burning pain, sharp pain. maybe shockwave is not the best option there because it's, they're having a combination of tendon pain and nerve pain, you know, because, because it's so close to the sciatic nerve as well. So, and when you're giving the shockwave, if you look at the anatomy, it's sort of the sciatic nerve is around three to four centimeters lateral to the tuberosity. So when you're giving shockwave, always, always aim medially. So don't go laterally. And obviously if a patient says, when you're giving, when you're giving treatment, I had, I've seen two patients actually, where they had raging sciatica after they have completed a course of shockwave where the patient complained having pins and needles while they're having treatment. So if a patient says they're getting pins and needles, you just stop. Maybe you're not on the right spot. Maybe you're on the nerve. You should not get pins and needles or numbness. So again, best not to choose patients who have a neurogenic involvement with the sciatic nerve. That's the key thing. Second thing is exposing it so that you can really hit the bone and you have to hit, you have to dig in. It's one of the most, I would say it's one of the most technically challenging shockwaves, the proximal hamstring, because it's intimate, it's awkward, and you have to really get bang on the bone as well. Well, another thing to remember here is, once I give that, let's imagine that I'm giving three or four weeks of shockwave, I find it makes a big difference to reduce the sitting time. So direct pressure on that. So I usually ask them to use like this sort of, You know like what you use for coccyx that sort of cushion You know very have the cut in to reduce that especially when they if they're involved a lot of driving and things like that To use the cushioning on that so they're not sitting and every 20 to 30 minutes to stand up You know not to have the direct pressure. So that's really important So the first thing is, you know Decent size the region not to put direct pressure a lot of times they go on internet and start stretching the hamstring and that just irritates things So really having shock with there's no point in doing your hamstring stretches or putting a foam rolling right onto the bone, we don't want that. We just want to desensitize the region. So a lot of time is education on reducing the, we don't want to say like sitting is harmful, but the way I say to them, you're just sensitizing the tissue around it. So use a cushion surface, try not to sit on hard surfaces, try to take breaks every 20 to 30 minutes, and also try not to overstretch it. So I think the main thing is desensitizing that sort of area. by not direct pressure and because a lot of people feel like, you know, putting a needle in or dry needling and you might feel a short term benefit, but that irritates that more and more. So reducing the direct pressure, reducing the sitting. And as I said before, stopping totally all hills and speed. I usually stop that for a good six to eight weeks, no hills, no speed, but they can continue with the flat. That's fine. The hills and speed usually retains that. So I think you have to be very, very strict. Let me give an example on lower limb. The one, where I'm very aggressive in my treatment is patellar tendon. Patellar tendons can handle it very well. So patellar tendon doesn't seem to, so I'm very aggressive. I'm not too worried about flat ups. In the two other areas where I'm very, very sensitive, where I give them very, very slow approach is proximal hamstring tendon and insertion alkydous. Those two areas are very, they take much longer than you think. So clear advice, taking the time. insertion of the Achilles, they also get flat up quite badly. So those two areas, it's definitely not easy, but as long as you, number one, don't irritate the nerve, make sure that you know your anus and knee, try to go always medial rather than lateral, reduce the sitting time, best not to stretch it. We know that stretching doesn't, you might feel good for a minute or two, but it doesn't do any much harm and definitely stop the hills and speed. And definitely it's not an easy one. So normally most tendons, if it, when I, When somebody comes to my with runners, so most lower-limb tendons, I say three to six months. That's what, you know, even with all my experience, I've not found a hack to make it quicker. It just takes time. You know, it takes six to nine months for you to really get a good results. There's nothing. There's no shortcuts there. As long as they know, it's a long, long drawn process and we need to decency. So I think the way to progress would be really. make them tolerant to sitting, you know, avoid local irritation, and then build up the strength, and then build up the volume, and then keep the speed on the hills to the last. So it's a very slow progression. So very hard to buy in people for that six to nine months, but you know, it takes time. So a lot of people, what they do is they go to a therapist, try for one month, it's not working, they jump to the next therapist. So I see the sort of people go under this conveyor belt, you know, I see this sort of they've seen three therapists, they come to me. And then they're disappointed because they thought I'll fix them in one month. Uh, and then they go around. So I'm sure, I'm sure you must've seen people where they, the runners, they go on in this sort of, they see six therapists because they don't want to hear that. It's going to sit here, take such a long time, but in my experience, you know, it takes that good six tournaments. Would you agree or have you found a hack? Uh, I haven't found the hack. Unfortunately. The, uh, I think that's a very good advice though, in those. three weeks, we're kind of desensitizing the proximal hamstring with sitting modifications, avoiding stretching, just taking it easy. But, uh, when you get into that 12 week phase, we're slowly reintroducing some levels of loading, we're probably still avoiding, uh, a lot of stretching, but we're seeing if you can slowly start to implement more and more sitting more and more strength work a little bit more running, but like you said that. the real powerful stuff that the plyometrics, the speed work, the hills, that comes at the very end of rehab. Once you're able to tolerate, once you have a really big base of, uh, load tolerance and strength. And the key thing would be not to change more than one variable at a time. So if you want to increase the distance, do that. Don't try to do the distance and the speed and the hills at the same time. The common mistake I see the best way to get injured as a runner is trying to change two variables at the same time. So, you know, for me, I want to build up at least 30 to 40 minutes of flat running with good strength, a good hamstring control and things like that, general lower limb strength. And then for me, I think the way I always, I've done it is build up the volume first, then go to speed, control speed work and then the hills the last. With hip patients, I always keep the hills the last. And that seems to work for me, because trying to do everything at the same time is just flats up things. So as long as you've got a sensible progression. you're not going to flat up. And again, even with the best late plans, I said to my patients, you're not going to see for eight months, I expect at least three flat ups, that's normal. So always pre-warn them that even with the best rehab, it's just getting a cold or a flu. You're going to get a little bit of occasional like a sore throat or something like that. So you're bound to have a flat up on the journey. For me, I expect at least three flat ups in that six to nine months. And then... The important thing is always, always give every patient expression of tendinopathy a flat-up plan. They know exactly one, two, three, four, five things to do. So for them, it's not a shock anymore. So they know that if I get a flat-up, so a simple flat-up plan could be reducing the strain, taking pen-keyless for three to four days, getting into the pool, reducing the sitting time, using a cushion, going to some cross trainer, taking a bit of easy on the running for a week and then going back. So a very simple flat-up plan can make a huge difference. So they know that it's like, an asthmatic has gotten or I know somebody with an allergy has got an epipen. So they know that they have a backup. So every runner should have the flat-up plan because they know that it's going to happen and we try to make them accept that it's part of normal recovery because a lot of people freak out when they get a flat-up and so oh god it's all back to zero. I was so I was doing so well and then I just screwed up by these things. I said that happens you know you're going to have one or two flat-ups so not to worry just you know calm it down and just back you go on the bandwagon I tried to downplay the flat ups and say, uh, I say to them on session one, you know, I could do it very, very slowly, but I can't prevent you from getting a flat up. It's going to happen. So let's get prepared for it so that you have a flat up plan. Is it something you give to your patients like a flat up plan for most conditions? Definitely expectations. Uh, I definitely agree with you with changing the variables, change one variable at a time, because we want to. learn how a tendon responds and you don't learn anything. If you try three things at once and it flares up, it's like, well, what flared it up? You have no idea. So documenting, writing things down and just being very patient with implementing one thing after another. Uh, with flare ups, I'd say that I do make sure they are aware that flare ups are a part of rehab and make sure that they do have a flare up plan in place, but just let them know that. When we are rehabbing a tendon, we're trying to find this. adaptation sweet spot and that's like, if we under, if we hit it too low, then it's not going to trigger any adaptation. But if we treat it too aggressively, that's when the flare up happens. But we know where the sweet spot is when a flat does happen. Cause we know, okay, we're slightly below that right now. Let's we learn from flare ups and we, as long as we learn from those flare ups and adapt it or modify your treatment as a response to that, then. You're just learning along the way and it's kind of like a good thing. Okay, now we know where your ceiling is. Yeah, and not as a therapist, especially as a junior therapist, I felt really bad because I felt things were going well. And when you get a flat up, you feel sad for the patient and you feel like you're responsible. And I think it's just acceptable. It's inevitable. It's inevitable. Part of rehabilitation is to get the flat up. So you get that with O&E's, you get with back pain, you get with tendon rehab. So for me, it's a part of the journey. It just makes you appreciate your success better when you've been through that sort of rough patches. So as therapists, you know, it's good to be carrying, but you know, not to get too bogged down when your patients get flat ups, because you know, as long as you pre-warn them on session one, because most people can take it as long as they know it's normal, that you're not damaging it. So if you tell them it's normal, so the key message is just like we use it with any pain condition, it's normal, it's expected, and it's not causing any structural damage, just a bit of sensitivity around the tissue, because it just overloaded. and your body just telling you, maybe I did too much. And the key thing, which I think this might be highly relevant here is a lot of runners don't tell you the total training load. So I've seen a lot of runners come by and say, I had a bad, I'm worse, I've not made any change. What they won't be telling you is they've been walking the dogs for four hours, two times a week in the weekend. They won't tell you the whole story. So a lot of patients don't tell you the whole load of they do. So sometimes what happens is they're doing the exercise well, they're doing the right rehab, but... their other activities in their other areas of the life are spiked up. Or maybe they have started a new job where they are now walking 18,000 steps where they were doing only 5,000 before. So it could be, that's why you need to be like a detective, try to find out all areas of their life, how much are they walking? So all my patients send me a log of the steps and their whole activity for the whole week. I keep a track of their whole life because as therapists, we can just stick to running and gym, but humans, you know, we have to look at the whole package, you know, what are they doing at home? How much are they working at home? How much are they working in the weekend? Are they doing like six Zoom classes like HIIT training on the top of your exercise? So all these things add up. It's the total load we need to look at. And obviously the psychological load as well, the sleep and other things, because sometimes the patient will say, I've been, I didn't do anything, but I got a flat up. It's not as simple as that. Maybe they've done a lot in the other aspects of their life, which they might not have. imagine they're not taught to let you know. So again, it's having that full connection with the patient where they can open up on all aspects of their life, both in the gym, but in the home and as well as with work aspects because sometimes it could be nothing to do with the exercise you've given, it's what they're doing in the weekends. So one perfect example, which we wind up would be, I had this plantar fascia, this patient, this is not a runner, but she was like in her late 50s. So she was doing everything. I was saying, but she was not getting better at all. So I just scratching my head and finding what, what should we doing? I think, I think she was from Nigeria or Ghana and where, because she had a large family show on every Saturday, she used to do like as a group cooking for the whole family and just freeze them. And she used to cook for about nine hours standing, bad food. So that was the trigger. And there's no way, you know, so I was digging my head and finding what was, why was she not getting better? But she never told me. And finally I've, you know, found what was she doing the weekend. So Sometimes there are some facts which they don't tell you, which could be one of the reasons things are not improving. So maybe they're doing something crazy in the weekend or they're just going six hours walk or some speed work with the dogs or some back to back Zoom classes. So we need to know the whole story so that we can give that appropriate advice because patients sometimes compartmentalize treatment. They just say some things to physio. They don't think we need to know the whole story. But as therapists, we need to the whole life, isn't it? We can't compartmentalize this work Fizio on running and things like that. I think a lot of the clients might not know that certain parts of their life are important when it comes to the rehab. Like you said, the cooking, and I do find they could be logging their mileage. They could be logging their speed. They could be logging their steps per day, but it's not until you find out that they're sitting longer or going for longer drives or stuck in traffic where the proximal hamstring might start getting irritated, or like you said, even just standing still can be a lot of load through plantar fascia and. they're just not aware so they don't share that information till people go digging and actually trying to work out what they're doing outside of their exercise. Yeah, brilliant. And as I said, for me, it's the whole package, isn't it? Like your life, we can't compartmentalize. The load is the load, whether it's a physical load, psychological load, as well as workload. The body acts as one unit. So it's really important to get that, and sometimes it may take a few sessions. before they open up, they feel like it's 11. So I guess you learn with experience that as a therapist, you're only doing exercise for that half an hour is that what happens to that 23.5 hours later, that's equally important, if not more important than actually what you're doing with the rehab, isn't it? Yeah, very, very true. We're gonna finish up here because we're out of time. Before we actually started recording, you mentioned that you had a shockwave module on which I found... coincides really well with this episode. Do you want to tell us more about that? Yeah, I think one of the things has been teaching for three, four years is a lot of international like when I when I taught in Holland and Belgium, the huge interest in online stuff, as you know, and nowadays, there's a market and there's a need where people want to see the hands on. So what I've done is linked up with physiotutors and created like an eight hours comprehensive online model where I go through all the conditions in detail. obviously make it with the latest evidence, the protocol. So I shared pretty much everything I do in my clinic, all the protocols, and even I've included ultrasound imaging. So it basically, you know, rather than coming all the way to London to attend one of my courses, you could pretty much sit anywhere in the world and watch the whole thing and there's quizzes involved. And also the best thing is accredited as well. So you get CPD points as well. So the site is stud So you can see the course here. And so I think this has been like eight years in his making. So what I thought was try to give a high quality forum because there's a lot of misinformation on shockwave. So I tried to take the best evidence and share the exact protocols which are used with my patients, all the conditions which I mentioned, and hopefully that can be benefit of patients. So for me, it's a small important tool, but again, it's knowing when to use it and how to use it. And the most important thing is the advice and the protocol you give after. So for me, the post. post-treatment advice, which I shared in the module, is as important because anybody can look on the internet and see the protocols, it's how we put it together. That's the main thing which takes a lot of, I guess it's a trial and error, but as I said is you don't have to do the mistakes I did. And hopefully you might find that useful, especially if you're using shockwave in your clinics. And it's quite common in UK, I think a lot of clinics offer that. I don't know the situation in Australia, is that common there? Uh, at the clinic I did work at last year, we definitely had shockwave and, uh, around the, the other clinics that I would attend, they're starting to roll some out, there'd probably be about 50% of, uh, modern clinics would have shockwave. It's a fairly common, common treatment as I said, is it's a simple treatment and, uh, and it's been around for 40 years and I'm sure it's here to stay as long as, you know, we know his limitations and pick up the right patients. It's a good, uh, for somebody, you know, my sort of The way I look at it is if you're physio dealing with a lot of lower limb rehab, especially tendon rehab, it's a useful adjunct which can help in certain patients, because we need to, the more tools you have in your toolbox, it might be a good option, especially if they're struggling with that. So it's not a magic fix, but again, it's relevant for certain people and it's good to have that option. And also runners are very clued on more and more patients, they call up and say, have you got shock wave? I read upon the internet. that it's good for Achilles tendon or proximal. So more and more patients are seeking for it. So clinics are realizing the need to have that in the setting to offer that. And if you have good quality clinical reasoning and good quality rehab 12 weeks after, that is going to really help you with your outcome. So if you're just giving shock in isolation, you'll be disappointed because nothing works in isolation in chronic tendon disorders. Yeah. Well said. And I'll definitely include those, the links to the physiotutors module in the show notes. While we're on that topic. I know you are very active on Twitter. Do you want to share those or other social media handles? Yeah. So I'm on most days on Twitter and LinkedIn. So my handle is at function to fitness with only one S at the end. And yeah, feel free to question. So for me, I think, you know, for me, it's just a I got into shockwave purely as a frustration with my runners and hit patients. So I wouldn't say like it's a very technically or very complex area. Again, it's knowing the reasoning for me. When patients look into shockwave as something huge or big, I try to downplay it. For me, it's a useful adjunct, but it's very simple. So let's not make it bigger than it is. And it's where I find many places underused and sometimes it's overused. So it's something which can be useful in certain patients. So I'm more than happy to take queries. if you have on Twitter or LinkedIn and hopefully that can be useful in your clinical work. Thank you very appreciate that and I want to thank you you've been very generous with your time very generous with sharing the amount of knowledge that you have and just it's I can tell the amount of passion the amount of expertise you can just go on and on talking about this all day so thank you very much for taking the time and sharing all the knowledge that you do have and thanks for joining us on the Run Smarter podcast. Yeah thanks for having me. Thanks once again for listening. To take full advantage of the knowledge you are building, you need to download the Run Smarter app. This contains all of my free access podcast episodes, written blogs and ebooks, along with my paid video courses, all neatly housed into categories for you to easily navigate through and find content you're interested in. 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