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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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In today's episode, Game Changers in Tendinopathy Research with Miles Murphy. Welcome to the podcast helping you train, rehab and run smarter. When I first started running in my 20s, I knew it would be something I'd be passionate about for the rest of my life. But, unfortunately, developing injury after injury disrupted my progress and left me under-trained at the start line on race day. Even with my knowledge as a physio, I still fell victim to the vicious injury cycle and when searching for answers, struggled to decipher between common running myths and evidence-based guidance. That's what this podcast is here to help you with. So join me as a run smarter scholar and let's break the injury cycle by raising your running IQ and achieving running feats you never thought possible. Welcome back everyone. We have a researcher on the podcast today. Miles Murphy is a physio. He is also a neuroscience and lower limb injury researcher. He has a paper with Ebony Rio, who, if you're not familiar here in Australia, she is a massive pioneer and just ahead of her field when it comes to tendinopathy research. So he's worked alongside Ebony and released this paper titled The tendinopathy game changes five papers from the last five years that might change how you manage tendons and goes into the papers that have emerged that have changed our understanding and just a wealth of knowledge. Obviously the person to have on the podcast and talk about tendinopathies, we talk about like the history or physiology pathology of tendons and what happens with mechanical overload and why they develop into tendinopathies. We then dive into some treatments. So talking about what the general consensus is or what the research shows around PRP, corticosteroid injections, shockwave, load management. We talk about flare ups, flare up management and a lot of tips that he gives throughout this episode is going to help you not only help and overcome your tendinopathies, but if you don't. end up with an attentional pthelia. If you don't have an injury helping understand the pathology around it to reduce your risk of developing in the future. So miles was amazing to have on very thankful for his time. And let's dive into the interview. Miles, thank you very much for joining me on the podcast. No worries. Thanks for having me. Let's run people up to speed about you. So about a bit of an introduction about your academic career and how you're sort of research, the direction of research has taken you. Yeah. So I guess I've had a bit of a mixed career because I started out purely as a clinician when I graduated my undergrad physio degree, I just could not believe that people did research. I thought research was for losers and I just couldn't understand why anyone had any desire to go down that pathway. And then I worked, you know, for almost 10 years as a clinician in sports, you know, traveling around Australia, working with different organizations from football to cricket, which was really cool. And then when I did my masters in sports physio, we had to do a small research unit. And I was like, Oh, this is actually isn't too bad. Because I think after a while, as a clinician, you start to get a bit frustrated at the fact that you just don't know the answers to things. So that sort of, yeah, drove me into looking into tendons because that was probably one of the pathologies that I found the most frustrating to, to manage because there wasn't a lot of research out there. And the evidence seemed pretty murky. Um, so I went and did my PhD in tendonopathy, particularly at the Achilles, so all of my PhD studies were in and around the Achilles. Um, and then from there, I still work clinically, but I don't travel with any sporting teams. I do a lot more complex case consulting for. you know, high level athletes or the everyday Joe blow that just has a lot of issues with predominantly tendons, mainly the Achilles. And then I've got a postdoctoral research role at ECU where I'm doing a lot of research into sort of the mind and the body connection as far as how the motor cortex drives things at the muscular and tenderness level. So yeah, not so much the psychological aspects of that mind body connection, but definitely the how the brain fires the nerves, which fires the muscles, which move the tendon. It's so weird having such a big topic of tendinopathy and you diving into it because there's not a lot of understanding about it, even this day and age and having their such a gap in knowledge and are still scratching ahead to certain topics of management for tendons, um, things you think we would have some sort of general understanding or like a good grasp of what works and what doesn't work. But it seems even these days, we're still scratching our heads in terms of really good management. Do you have any particular reason why that is? Um, I think the, the hard thing is for tendons is that it's not something that costs the healthcare system a lot of money. So if you compare tendon pain to osteoarthritis or low back pain, osteoarthritis and low back pain cost governments millions and millions and millions of dollars every year. Tendons mainly affect physically active people. It also affects your sedentary, non-physically active population, but traditionally it's always been thought of an athletic problem. And the reality is the government just doesn't want to fund research into why athletes get sore areas of their body. Interesting. So the amount of funding for tendons is almost non-existent compared to the amount of funding in osteoarthritis. And if you want to run big trials, if you want to have big databases and you want to get some really good answers, the reality is you need some money behind it. And in the tendon space, that's definitely not there like it is in the low back or in the, the joint injuries. Never thought about it that way. Um, good to know. Well, based on your understanding when a tendon like develops into a tendinopathy, like what's, what's going on there? Like why did tendons develop this sort of pathology? Yeah, so I think that the big thing when we talk about tendinopathy is to be very clear about what we mean, because you can get tendon pain from a lot of different drivers. For example, you can have inflammatory tendon pain, and this would be someone that has rheumatoid arthritis, psoriatic arthritis, some form of, you know, systemic inflammatory condition that gets tendon pain. they're not exactly what we would consider a tendinopathy per se. So when we talk about tendinopathy, we're really thinking about those tendons that are mechanically overloaded, they get aggravated with mechanical loading that have had too much mechanical loading. So I think that's the first thing to differentiate is you can definitely get sore tendons if you've got other causes. Okay, so the inflammatory conditions are one. Another cause that's not everyone's aware of fluoroquinolones, which are a high, really potent antibiotic, which have a really nasty effect on tendons, particularly the Achilles. So the most common side effect, or not the most common, but one of the big side effects of fluoroquinolones is Achilles rupture. So people just spontaneously rupture their Achilles after taking that, but you can also get fluo tendon pain. So people take them and then all of a sudden they start getting sore tendons. So there is other reasons, but... What I'm going to really talk about is the mechanically induced tendinopathy and, and they're the person that has an overload at the tendon from tensile and compressive loading. So in my head, I always think about three types of load that tendons can do. First is tensile, which is stretch. Obviously, if we think of tendons like an elastic band, their main function is to stretch and we want to get that elastic energy that's generated from that elastic tendon. to help propel us forwards or upwards or whatever we're doing. Then there's compression. And this is the load when you stretch a tendon or contract a tendon over a little bit of bone. So the compressive loads typically occur at the insertion point of the tendon. And when you look at the anatomical models, we know that at the insertion of the tendons, right before the insertion, there's always that little bump. And that's essentially. designed to give us a bit of mechanical advantage. It's designed to act like a little bit of a pulley. So we know that there's a lot of compression in that insertional zone. And that's why, other than the mid portion Achilles, all the tendinopathies occur at the insertion. They all occur at that area where there's that compressive element. And then the last type of load is shear, which is more of a friction and sliding and gliding load. That's not as aggravating for tendinopathy. Okay, so the shear loads If someone's got like a paratenonitis or tenosynovitis, the sheer loads are really provocative. But if someone's just got tenonopathy, they're not really aggravated by those sheer loads. It's more the tensile and the compressive loads, particularly in combination that will cause that. So as an example, if we have a runner and a runner is, you know, doing a weekly volume of let's say 60 Ks, and then all of a sudden they decide that they want to do a marathon in a few months, so they want to increase their weekly mileage and they aggressively increase that weekly mileage. There's a big increase in the amount of tensile load that goes through the tendon. There's also a big increase in the compressive load that occurs at the tendon at the insertion site. And when you look at where tendonopathy occurs, as I said earlier, it's typically at that site of mixed compression and tensile loading. And it's that combination that the tendons not prepared for. that sets it on the pathway for tendinopathy. I think it's, it's nice to get that explanation because a lot of people, when they, especially runners, when they develop an injury, they're like, okay, is it my shoes? Is it my warmup? Am I not stretching off? Like, uh, healthcare professional looked at the way I run and they said that I, you know, cut in or like I have a leg length imbalance or I have, you know, a stiff overactive clut or something like that. Uh, but. In reality, those might be like very, very fine grains of sand in their overall presentation, but for the most part, if they've built up their volume or they're training for a race or they've been introduced too many hills or something that's very much changing their mechanical load, that would be more of a reasonable explanation. Yeah. So all those things, or not all of those things, I think the, the weird stiff glute thing you mentioned, we might throw out the window, but And for the rest of them, they are for all things that can throw someone overboard. So when we're looking at loads, it's really looking at the total load that person is exposed to. And your overall capacity, and I'm completely stealing this from a lovely editorial that was written by Jill Cook and Sean docking, where they sort of said that your current capacity for your tissues is only just below your total capacity. So if you try and change things rapidly, you're probably going to overload your total capacity. Because if you're sitting here, you know, at whatever level it is, and then you try and push and you push beyond your capacity, something's going to be overloaded. Now, if the tendons overloaded, that will, you know, reasonably get tendinopathy. And yet, mechanical loading by doing extra running is a very obvious one. But it can be subtle things. Like if someone goes from a shoe, let's say someone usually runs in a shoe with a monstrous heel pitch, so something like a Hawker that has that really large heel posterior to anterior with the the pitch, and then they transition to something that had a pitch half that size. If they're a heel striker with their run pattern over the course of, you know, a thousand strides or a thousand impacts, there's actually a lot more excursion of the Achilles. So they're actually going into a lot more dorsiflexion. And we know that for the insertion Achilles, that the dorsiflexion position puts you into more tendon compression at the insertion. So those shoe changes can irritate a tendon, but Generally, loading is the big one. And it can also be the type of running. So it can be that the runner who's always run their normal track, because they wanna increase their volumes, or even if they just wanna mix it up because they're getting a bit bored by what they usually see, they might pick a slightly different running track or running course. If it's more hilly, we know that when you run up a hill, you tend to have an increase in the amount of dorsiflexion through the ankle. So it is reasonable that might overload the Achilles. Or the other thing is if someone's transitioning to a forefoot or midfoot run cycle, so they've always been a heel striker, and then they try and run forefoot, all of a sudden, if you're a heel striker, you probably don't use a lot of calf, you're heel striking and conserving calf energy, and you go to a middle forefoot strike pattern. If you do that too quickly, you can really overload again the calf and the Achilles so that all those things can happen. And that's why whenever you see someone with an Achilles, or if you have an Achilles problem, you really want to interrogate all the things that you've done differently. Because if you're already running at the volumes that are, you know, almost your max, and then you change those things that seem little, it can be just enough to push you over the edge. But I would say that's more what I see in a higher level runner in the general runner. it's typically the big distance changes. Cause once a runner likes a pair of shoes, they tend not to want to change their shoes. They will tend to just buy the same shoes over and over. So we probably don't see shoe changes that much unless they've seen something on TikTok or something and want to get a bit different. But definitely the running volume tends to be the, the biggest one is that they just ramp up way too quickly. And the other one that can be quite subtle, which is really important to ask about, is the run frequency. So we know that tendons in particular really dislike repeated impact days. So it might be that you've got a runner and you say, okay, what's your weekly mileage? Yep, 60 Ks, cool. What do you usually do? 60 Ks, has anything changed? Have you been doing heels? Have you been doing this? No, no, no. And you're like, oh, well, I can't figure out why this is being a problem. It might be that their work schedule's changed. And instead of running, you know, 20 Ks three times a week, as an example, they might be running 10 Ks six times a week. And without having those rest and recovery days, even though their weekly mileage might actually be exactly the same, and nothing else has changed, because they're not getting as much recovery through that tendinous elastic tissue, that can be the thing that actually causes the irritation. So it's, it's really important to interrogate why it's come on. And I know whenever I do any of these consults with the group with the Achilles, I probably spend most of my time figuring out exactly what they've been doing in their life and what's changing because I can give the best program for whatever I want to do, but if I've missed what's driven the flare up in the symptoms, it doesn't matter what you do, you're not going to fix the problem. Probably a good tip as well for those who have a currently managing a tendinopathy and returning to running. If you're, if they're, um, doing back to back running days and they need sort of that extra 24 hours for the tendon to, you know, adapt and synthesize and that sort of thing, I think the, uh, it's a good tip to maybe separate them out. Maybe run every second day. If you're really struggling to manage that current load or struggling to, uh, heal or see improvements with that particular management strategy, like I would in my. Achilles patients that I'm returning to running or anything, it's very similar to what I do with bone stress injury, is I'll get them to do this, like, you know, whatever mileage over a few days to make sure that they've got rest days programmed in the early phases. And even if that might be the same volume as what they might have done every day overall, so always try and go for a longer running session, but less frequently, then try and do it every day because the worst return to running program you can have for an Achilles is where you run every single day. You want to try and if you've had a big problematic tendon, you want to try and break that up. Now you can be doing other things on the other days. You can be doing resistance training. You can be doing other forms of cardio, but definitely in the early phases, you probably want to try and mix up the, uh, the days between loading impact and non-loading impact. Yeah. A lot of. advice or maybe early advice or someone's intuition when they do overload their tendon is to rest and let things recover and see how things go. And that might be a couple of days, that might be a couple of weeks, pending how irritated it is. But for those who may have listened to other episodes this podcast, they know that complete rest usually isn't recommended for tendon or overuse injuries. Why isn't it recommended? Why doesn't that work? Yeah, so well, it doesn't, it doesn't. So the reality is if you've got a sore Achilles from running and you stopped running, your Achilles is probably not going to be that sore. So it does decrease symptoms. The problem is flipping back to what I said earlier is your capacity of your tissues only just exceeds what you're currently doing. So if you are used to running 60 Ks a week, and then you get a sore Achilles and for a month or even for two or three weeks, you run zero Ks a week. And then you go, Oh, my Achilles is feeling really, really good now. Cause I've given it all this rest. And then you go back and try and go back to the same schedule of running 60 Ks a week. You were overloaded doing 60 Ks a week because you had a sore Achilles. You know, that suggests that you're overloaded and then you've done nothing for a few weeks. So your running capacity has dropped off even more. And then you've gone back and tried to hit the exact same loads and you're actually overloading it and even higher level than you were before you rested. So that's why for tendons, rest is so problematic because if you do complete rest and you don't maintain some form of capacity through the muscle and the tendon, you lose so much conditioning. So if you just think of it like a fitness point of view, if you wanted to run and let's say you ran whatever, you know, K per minute Ks time, and then you took a month off and then you tried to run that exact same tempo, you're probably not gonna be able to run it. Or if you do try and run that, you're going to have a much shorter run because you're going to burn out really quickly. And it's the exact same thing for the tendon as far as its capacity is that as soon as you take time away from loading, the tenants capacity drops off. So when you get back into it, you've got to be really aware of that. So I always talk to people about relative rest. And if someone's got a sore Achilles, instead of saying, well, stop running. It might be, well, you need to drop off one of those running days. If you're running four times a week. five times a week, you drop off a session. So I'll try and reduce their volume, but to the minimal amount of reduction to settle their symptoms. And then as they get stronger through exercise, rehab and whatever else that we're doing, I'll try and push that volume back up again. The hardest thing with tendons is that they warm up. So you have a sore tendon when you start running and then it feels better as you keep running. So you can actually, a lot of people will just keep pushing and pushing and pushing, but what they notice is that time to warm up just takes longer and longer. It's not warming up as well. It's really causing a lot of problems then in general life because they're taking a lot of time to walk after they get out of a chair because their tendons so stiff and sore. So you need to be pretty conscious of those things because it's not always the pain or the problems during the activity that caused the biggest issue for the. Achilles because they do tend to warm up nicely. But rest is not helpful completely if you go back into those same levels of loading. So my advice would always be that you need relative reduction load. So you want to do less. And but probably the easiest way to do that is just drop one day. And sometimes, like I said earlier, they can actually keep the same running mileage, it might just be that they run one less day. So if they're a 60 K a week runner over four days and you drop them to 60 Ks over three days, that might actually be enough to make their tendon feel a lot better because they're getting more rest days, but it still gets that same mileage through the tendon, you got to play around with it. You've got to meet the person at what they're telling you because sometimes people's schedules aren't dictated by what they like to do, but what they've got the time to do. So it might be all good and well to say, okay, we'll run more on these days. And they're like, well, because of my work home family schedule, that's just not a possibility. Well, you can't do it then. So. just talk to whoever it is and figure it out. But yeah, try and have a reduction in load enough to settle your symptoms a little bit, but not completely remove loading. Good advice. I'm trying to take off that minimal amount of load required to get the, to foster some healing or load management for that tendon. Um, you highlighted some key points there. I guess it's just like following a trend sort of day by day, week by week, not only just with your running or well sort of characteristics within your running, you mentioned, okay, it has a warmup effect. So we can't really judge a lot about the run itself, but maybe there's a trend of how long that warmup effect takes. Sometimes it might take two minutes before it's warmed up in your symptom free. So, but then next week, that two minutes might turn into 10 minutes and it means your maybe continuing to overload that particular structure. And so paying attention to that particular characteristic, but then maybe after the run, like later on in the day, the next morning, how stiff is my tendon? How long does my morning stiffness take to warm up if I'm sitting for an hour meeting, and then I get up and move around how stiff is my tendon and how long does that take to wear off? And so focusing on those. particular characteristics of whatever relates to that particular patient, whatever tendon might be irritated. And just seeing a general trend as you continue to load throughout the week is that are those characteristics improving? Would that be fair to say? Yeah, the thing that I usually tell patients to use, which is, I think probably the most accurate is that symptoms the next morning. So when you get out of bed and try and walk to the shower or walk to the kitchen or whatever it is that you're doing, how stiff are you out of 10? If that's the same every day, you're probably in a good loading pattern, that's getting worse, you're overdoing it. And if that's getting better, you're probably either going really well and improving or you've dropped your loads too much. And that can be a good guide because yeah, pain during the activity is a pretty poor indicator of someone's tendon health because they do have that warm up effect. And I know, with say an athlete group, if you're training for an event, it might not be reasonable, it might not be feasible to try and improve your symptoms. And what I mean by that is that if we've got to get a certain amount of mileage in to make sure that you're okay for an event, we might say, okay, well, let's focus on morning stiffness always being a four out of 10, and we'll train you to the four out of 10, and we'll keep you at whatever volume that allows a four out of 10. And then as soon as you've gotten through whatever event it is, that's when we work on actually reducing the pain, reducing the symptoms. So it's often a trade-off as to where you are in, you know, other sports like football in season. Obviously we're gonna be more focused around keeping the pain levels relatively stable because we don't wanna drop them off because we want them to be playing every week. Whereas as soon as the off season and pre-season comes around, you're probably gonna have a lot more capacity to drop off volume, to do everything else that you need to and make sure that you're settling the pain and the symptoms. So. depending on where the person is in their loading cycle and where their events are, it will also make a difference as to what your goals are. Great. You mentioned like the morning stiffness doesn't necessarily need to be pain or can be pain and stiffness, maybe just stiffness, maybe just pain, just localized to the tender, not anywhere else. So we, if a runner is listening to this and trying to feel out those characteristics, it can be one or the other. Yeah, most, in my experience, most Achilles tend to report more stiffness in the morning. They don't tend to report a lot of pain. They just feel like the Achilles needs to warm up when they get out of bed. It's not necessarily described as pain. I guess some people probably would describe it as pain, but most people just report it as being really stiff and needing to loosen up. And it definitely is in the Achilles. Like if you're, if you're getting soreness in your calf, if you're getting soreness in your hamstrings, but not your Achilles, that's probably a good thing. It means you're working the muscles and not overloading the tendon. So yeah, we're really talking about that isolated stiffness in the Achilles, that tight feeling, um, that takes a little while to warm up in them in the morning. I always like to encourage people like Or at least celebrate with my clients that are managing a tendinopathy when they load up their tendons with some like slow, heavy load in the gym with their rehab program. And then the next day they actually have delayed onset muscle soreness rather than tendin stiffness. Cause it's like, Oh, fantastic. Now we've sort of reached a certain threshold where your muscles are actually being stimulated enough to get stronger rather than your limitations being a particular tendon. So, uh, always good to. recognize that because some people might wake up and actually have doms and be like, oh man, I'm worse than what I was. These are worse off symptoms. And so we need to sort of recognize the difference between that generic muscle soreness, which is in the muscle and quite widespread compared to tendons, which is fairly localized just to the tendon itself and, you know, separating out those characteristics. And that's, that's a really good point. And that's something that I'll always tell my, um, athletes or whoever it is when they're leaving, I'll say, listen, If you go and do my program today, you're gonna hate me tomorrow. You're gonna feel absolutely terrible through your calves and whatever else I've programmed for, but it shouldn't be your tendon. I go, you should really feel sore and terrible everywhere, but where your injury is. And if that's the case, that's a good thing. So yeah, I always give them the heads up because you're right. Like we sometimes forget that, well, we know that's normal. Not every patient does. And they just assume that soreness is linked with a flare up. So it's yeah, really important to. let them know that muscle soreness with some form of exercise loading program is expected. Yep. I wanted to dive into other common practices for tendinopathies other than the load management that we just talked about. Uh, some of the popular ones, uh, injection therapies, PRPs, corticosteroids, and those sorts of things. And wanted to get your take on the current understanding, current literature where we're at. Can we start maybe with. into a tendon for management and get your thoughts on that? Yeah, the PRP literature is quite confusing. And particularly if you just read the conclusions of the studies, because some of them will say that PRP is really effective long term, others will say that it doesn't have any effect. The first thing I think that you need to be just really conscious of is what they've compared it again. So if we start talking about cortisone, I know you said PRP first, but it'll probably be easy to talk about cortisone. We know that with cortisone, with tendon pain, when you get an injection, you get this very good analgesic effect. So we know that people after a cortisone tend to feel pretty good in any tendon, whether it's the elbow, the rotator cuff, the glute. When we look long-term, however, that group tend to do worse. So if you've had a cortisone, you might get short-term symptom relief, but you tend to be worse long-term. And what some of the PRP studies do is some of them compare to saline, so placebo injection, some of them compared to cortisone. So there's a number of studies in the PRP world where they say, oh, well, at 12 months, PRP is superior to the control group, but the control group was cortisone. So if you actually look at what happened, the PRP group didn't have any change. They stayed exactly the same over the 12 months, but because the cortisone group got worse, they report that PRP is better, even though they're actually no different in their symptoms. They had the exact same symptoms as when they started the PRP, but because they're comparing to a group that got worse, it's like, oh, PRP is fantastic, P value is less than 0.05, let's all do PRP. So it's really important when you read these studies to look at what they're comparing against, because any therapy that's comparing against cortisone in the longterm, even if it does nothing, is probably gonna show that it's effective, because we know that cortisone makes people worse, and there's a lot of evidence supporting that. Cause that's the first thing I think with PRP. The second thing is I just don't feel super comfortable injecting or, or with patients that have had tendon injections. Um, if we, if we talk about cortisone, I don't really think there's many people out there that will still do cortisone into an Achilles, I think that's pretty. Finished, um, because we know that the likelihood of rupture after you stick into the tendon is extremely high. So there's very few people that will do it and very few people that would risk it. And what's probably more common for cortisone is the group that have paratenin pain. So the group that have the parateninitis, you can have cortisone injections into the paratenin. And they tend to go okay, I guess, I don't necessarily think they're needed. I think you can manage those groups really well without them. But they're into the parotenin, they don't actually inject into the Achilles with the cortisone. And the other group with the cortisone is the high volume or corticosteroid and saline injections that are injected again, not into the tendon, but next to the tendon. And it does a very simple thing, a similar thing with the parotenin and the sheath and the lining. So they just don't seem to, in a tendinopathy group, do anything. So there's a... couple of good randomized control trials of the high volume cortisone and saline injections just so that they don't really seem to do anything beyond just the effects of the cortisone. And because we know long-term cortisone is not the best idea, I wouldn't really be advocating for that with any of my patients. And then I guess the thing with PRP is that the... The evidence again doesn't suggest that it's very good at improving pain and function beyond a placebo group. And I don't really, I guess, understand the biological rationale. And what I mean by that is with a tendon, we've got an area of tendinopathy, the degenerate area of the tendon. But that part of the tendon doesn't do anything anymore. It's not got tensile capacity because the tissue is not connected in a way that can actually perform tensile loading. So it's not the part of the tendon that's even involved in being able to do running and jumping and all those tasks that work the Achilles. And we know from the ultrasound tissue characterization research that was led by Sean Docking that even if you've got a big degenerate chunk of Achilles, the Achilles still has a volume of good tendon tissue that is comparable to their uninjured tendon or to people that don't have tendinopathy. And the whole rationale for PRP is to inject the tendon to get more good tendon tissue, but we've already got an amount that is comparable. So I just don't see in this group why giving them more collagen, more growth factors, all these other things that it's designed to promote is going to fix the problem when they've already got a sufficient amount of good tendon. And again, I use this example a bit with my patients is I'll get them to do a calf raise and on their sore Achilles side, they do four and on their non sore side, they do 18 or something. And I said, Okay, I could inject that with anything. It's not going to make you do more than four calf raises. So I think the biological rationale that it improves the structure is fine. Maybe it does. Okay, I don't think there's a lot of evidence that it does, but maybe it does improve the structure. But we know that the relationship between improvement and changes in structure is non existent. There's a lovely case series done over a number of years by a group in the Netherlands, Robert Yandervos group, where they looked at UTC ultrasound character tissue characterization over a two year follow up of people with Achilles pain. And what they showed was that it didn't matter what your tendon looked like and how it changed over that period of time, it had no relationship to how you felt. So I just don't see how a intervention that's targeted at improving just the structure is likely to then improve symptoms when we've got a lot of evidence that shows that relationships non-existent. So I think that's probably where I stand on PRP that a lot of the arguments are for its biological rationale. but we know that the biological, um, rationale when it's linked to things like pain is pretty poor. So yeah, I'm not someone that advocates for PRP. That said, it's not uncommon that I get patients that come in having had multiple PRPs and other things. And I think the worst thing that you can do as a clinician is go, Oh my God, what was your doctor thinking? PRP is a disaster. You shouldn't have done that because they've probably just spent a lot of money on these things. And I think it's really important that you go, okay, right. You've had the PRP, you know, that's designed to, you know, improve your structure. I won't go into probably more detail than that, but I'll say, you know, I've done your calf raises, you can only do four. The PRP is not going to fix your calf raises. So we've got to work on that. The PRP will do whatever the PRP does, but we've got to work on your strength and the conditioning of the calf muscle. Cause at the moment, it's just not up to scratch. And I'll approach it that way. So I'll still point out their physical impairments. And I'll try not to get too bogged down in the injection talk, because I think it's a real way to just destroy someone's confidence in the healthcare system and, you know, everything else by telling them that an intervention that they've probably spent a lot of money with is a waste of time. Instead, I'll talk about the things that I just did is that, okay, cool. You've got these changes on the Achilles. We know that just because you've got changes, it's not a death sentence for your Achilles. You can be a hundred percent normal, even though your MRI, your ultrasound looks like that. The things that we know are important are your, you know, controlling your mileage, controlling your risk factors for aggravation. Like, you know, don't be changing shoes every second week because you're just trying to find the right pair of shoes to fix your Achilles and all these sorts of things and get stronger. Make sure that you've got good capacity through the muscle and the tendon. So I think that's probably my stance on PRP and cortisone is that I don't think they provide much value in the management of someone with tendinopathy. And the other big concern that I have with both of them is that irrespective of which injection you get, they'll usually put you in a boot or they'll tell you to decrease your volumes for weeks and weeks and weeks. And if we go back to what I spoke about at the beginning of this, the more you decrease your running volumes, the more deconditioned your muscle and tendon become. So you need even longer to build back. Um, and when you're trying to, you're taking more time off to change the biology of something that might not be that relevant to the presence of pain, it just seems very counterproductive for me. Yeah. What you said before was really interesting talking about, okay, if you have this chronic degenerative tendon, that is portion of the tendon that is now non-responsive. And our goal now is to build up the capacity and strength of all the regular healthy tendon around it. Uh, it can be very hard for patients and runners to like, based, if they have so much pain, they've got so much dysfunction, it could be easy for them to think that the entire tendon is degenerative and about to rupture and like, you know, all this really catastrophizing. ideas. Can you speak to like even like moderate to severe cases or really chronic tendinopathies? In some cases, you've seen like how much of the tendon is actually degenerative? Like, are we talking 50% of a tendon? Are we talking 10% of a tendon? Can we even speak to that? Do we even know? And yet we know, and there's some good work by Sean docking in this space. Now, I couldn't quote the exact percentages off the off the top of my head, but some people can have, you know, huge amounts of degeneration within their tendon, but they still seem to maintain a very good volume of good tendon tissue. If your tendon didn't have enough good tendon tissue, that's when they tend to rupture. But the thing, and I tell this to my patients and I never know if it reassures them or not, but I say, listen, the reality is painful tendons very rarely rupture. you're far more likely to rupture your non painful tendons. So don't worry about the side that's sore. It's the other one that's more likely to snap. And they're like, oh God. But they do actually, I think, find it quite reassuring to know that just because it's sore, it's not going to actually rupture. And the fact that they're getting pain, the theory from, you know, people like Ebony Rio, who just a master in the tendon pain space, so that the area of pain and that where you're actually getting the sensation that's driving pain output from the brain is not actually from the degenerate part of the tendon, it's actually from the part of the tendon that's healthy, that's transitioning to become degenerate. So yeah, try and shift away the focus from the part that's garbage to the good part, and keeping the good part of the tendon as healthy and as functional and optimally loaded as possible, as opposed to focusing on the degenerate portion, because you can't change that. I don't think there's any good evidence anywhere that is useful. And all the surgeries that they used to do used to be about going in and cutting out the degenerate portion of the tendon. And I don't know anyone that does that anymore, because it just didn't work. So the pain doesn't seem to be driven a lot by the degenerate portion. And we used to think it was all about neovascularization and the in-growth of blood vessels and nerves through the degenerate portion. But again, the relationship of that to symptoms was really poor. And we know that... people have a lot of changes in their Achilles and don't have symptoms. There was a huge systematic review in the Journal of Orthopedic and Sports Physical Therapy a couple of years ago now, that actually showed your biggest risk, or the reason that people had tendon degeneration was actually the amount of mileage they'd done in their life. It wasn't related to whether or not they had tendinopathy, is that the Achilles gets thicker and changes more as a response to impact loading to adapt, as opposed to... because you've had symptoms. Hmm. And I've had a lot of clients that get scans of their degenerative tendon. And they see a whole bunch of changes. They see some thickening, they see some small tears, they see, um, you know, some rapport, like inflammation of some sorts, but then they scan their other side and shows us very similar things, even tears. I've had people have very healthy. Non-symptomatic. Uh, non-symptomatic tendons on the opposite side. And even they show some tears in the tendons and funky stuff that's going on there. So maybe that is just day to day, year by year, just lifetime loading tends to create some of those changes. Yeah, and tears are an interesting one. Because the thing that's reported a lot in the Achilles, the longitudinal split tears, as opposed to transverse tears, I guess. And I still can't really figure out what a... longitudinal split tear is, because I don't know how you can tear something that isn't technically connected. And there was a really good study, I think Angie Fearon led it at Uni Canberra, where they looked at the glute tendon. And they compared imaging findings of a tear compared to what sort of they found when they went in histopathology, histopathologically in surgery. And MRI is terrible at actually picking whether a probably throw that terminology around a lot. So I tend to, if there's some, if it's completely ruptured on the scan, that's a bit of a different story. But if someone's got a presentation where it was a gradual overuse pathology, irrespective of how bad that scan saying they've got as a tear, I'm treating that like a tendinopathy. I'm going off the clinical findings as opposed to what's on the radiology. Yeah. I deal a lot with proximal hamstring tendinopathy and there's some presentations where it's like, okay, I slipped on ice and I felt this big pool pain, immediate pain in my high hamstring, and then they have scans and they show a tear. Compare that to someone who's was training for a marathon. Like you say, slow onset, gradual onset as I built up my volume, no real one instance. but then they scan their tendons and they have a tear. And I'll treat both of those extremely differently just because the onset is completely different. And like you said, let's treat it like a tendon. Let's see if it gets better. And if it does, then that helps increase our confidence that we can continue treating it like a tendon. So I think it can really trigger a lot of fear and anxiety and people can catastrophize a little bit when these MRI findings are found could be quite alarming in the language that they use. Yeah, I think the biggest problem with the word tear is if I spoke to my mom and I said, mom, you've got a tear in something, she'd go, oh God, well, the worst thing I could possibly do is do any loading. Because if I load something that's torn, it makes it worse. Whereas we know in the tendon space that if you don't load it, it gets worse. So I think that's probably the biggest issue with the terminology of tearing is that the general. lay person, here's the word tear and automatically goes no deal. I'm not doing any exercise onto that. Or they're really hesitant to do exercise onto that, which is yeah, inherently problematic. Cause that's where the best evidence lies for these conditions. Hmm. Um, back to the question about the degenerative tendon. Um, do we have like a percentage, like in the severe cases, how much of the tendon might be degenerative? I don't know if the top of my head would need I need to phone a friend. But okay, it can be a very large proportion. I think the thing though, to remember is it's only in one specific section of the tendon, it's not the entire length. And it's not the entire breadth. So in the Achilles, it tends to be either on the medial aspect in the patellar tendon, it's always in the middle. So that's where the whole expression the donut is ignore the hole and just treat the donut. because the bit in the middle, irrespective of how big the size of the hole of the donut, it's the donut that's important. So people can have quite substantial changes in their tendon structure. Like I said, I can't I can't quote the percentages, but it'd be very large and be completely asymptomatic and doing extremely high level sporting activities and never know about it. Yeah, good to know reassuring some people. Where are we on shockwave? Cause that's, there's a, you know, to my knowledge, some research on that. There's been like rather large studies on it. I'm not too familiar with the, um, the outcomes and those sorts of things. What are you, what's your take on shockwave? Yeah. The evidence for shockwave is definitely better than I think the evidence for PRP. Um, so if you were going to do anything above and beyond normal exercise, loading shockwave is probably the best bet. I actually don't use shockwave in my practice. And there's a couple of reasons. Firstly, there was a pretty neat study out of Latrobe that looked at shockwave in healthy tendons. And when you shockwaved a healthy tendon, you actually induced a reactive tendon change. So all of the changes on the ultrasound tissue characterization that we associate with the early stages of tendinopathy actually occur when you performed the shockwave. which in my head, I can't see why that would be a good thing is if you're inducing something that is bad, why would you do that in a bad tendon? Um, but the, the other thing that seems to occur with shockwave, and it's definitely evidenced by some of the adverse events is that you, you get this sort of transient neuropraxia where you get this reduction in the capacity of the, um, sensory tissues, because some people do get, you know, proper neuropraxia after shockwave, if the nerves been hit too, um, too much. But I think what it does, I think it's a relatively effective method to reduce pain. So that's why I think the effects of shock wave help is I do think it probably helps with pain. I'm not necessarily sure what the long term ramifications are. The reason I don't recommend it is that if someone has pain from a tendon problem, and it's a mechanically induced tendinopathy, and their stiffness and their symptoms are really their guide as to how much loading they should be doing on their tendon. So yeah, I don't tend to recommend very heavy painkillers or anything either, because I use that pain as a part of their rehab to know how much I want to be giving them, how hard they should be pushing, because they probably should have pain with some activities, but if it's substantial, they also need to be able to back off from those tasks. So I think the evidence is better for shockwave. It's not something that I use myself. And we don't even have one in my clinic, but it's not something we use. But I do think if you were gonna choose between shockwave and PRP, I'd definitely be referring for shockwave before PRP. But I think provided you give really good education and a really good rehabilitation program, even shockwave isn't necessarily that beneficial. I find in the people that I've had that have had shockwave sometimes is good for that person. That let's say they come to you and they've seen six physios who have all given them exercise. Now you might look at the program and go, okay, well, I think you probably needed to do this or I don't think that was good enough and we didn't address your load and blah, blah. But I think sometimes those people that have no hope, it is useful to almost, you know, go, okay, well, we're going to redo the exercises. I think these my exercise will be better for this reason. We've got to hit these KPIs. We've got to change your running because of this. We've got to drop your volumes, whatever it is. And then maybe you send them for shock waivers as well. And even it just hoped for a bit of placebo effect to get some capacity to do the program. But yeah, it's not something I routinely refer for but I do think the side effect profile from shockwave would be substantially less than that of. plasma injection and cortisone. Yeah. Can I maybe, um, share what my understanding is or what, who might be a good candidate for shockwave and see, you might want to chime in to see if you have any differing opinions. Uh, cause I like to say to people, there are good candidates and there are bad candidates, the shockwave doesn't really heal anything, it doesn't heal a tendon, which some people think that it might. Um, What I like to, or how I kind of like to explain it is you want a, a good candidate would be someone who has a really strong tendon, they've done their progressive loading or they you've got a sense that they've got a high capacity for strength. Um, cause I don't want to be pummeling like a, a weak sensitive tendon. Um, but there are certain people who are non-responsive to progressive strength training. They've done their. You know, three to six months of strength training. And they're not this, they've got this real stubborn low level dormant kind of tendon. That's like a one or a two out of 10. It's just not changing, not differing, not budging, just being really stubborn. And we just need it to be a little bit more reactive to then see if restarting another loading program after shockwave might be a little bit more responsive. But then reminding people, you know, weak tendons, probably not best. really sensitive tendons, probably not best and give the, the strength training a go first and then see if it responds. Well, if it's still really, really stubborn, then we might give you some shockwave, maybe try three to five sessions. Don't do like if you, if it's, if you're not seeing a good outcome in five sessions, don't push and do 10, 15 sessions. Cause I've seen that done before. Um, give it a try and then reevaluate after that. Anything I've said there. Uh, you disagree with or any different opinions? Well, I can't really disagree because I don't, I don't use it. So I'd be pretty happy to defer to your judgment on that. Cause like, I don't use it as a part of my practice. I'd be just, I don't think I'd probably be a good person to say who I think it would be good to use and not. I don't think there's probably any research yet that shows who the responders and non-responders are. So the clinical evidence, like you just said, is probably our best bet. Um, I do, I think the rationale for what you're saying makes sense to me. Um, if you've got someone that's just grumbly and niggly, but everything else seems to be looking good, you know, throw something out there, provided the side effect profile is relatively low, which for shockwave it overall it is. Um, so I think it all, yeah, I think that all made sense. Um, yeah, I just wouldn't be able to, yeah, I definitely can't disagree with you because I don't do it, but I think everything you said made made sense to me. Fair enough. And I, I really suggest encourage shockwave. It's mainly just because a lot of clients that eventually filter to me have already been through the ring out. They've had PRPs, corticosteroids, shockwaves, and they've done all those sorts of things and they start to think maybe revisiting some of those might be a good solution. And yeah, it's really hard to say. I, I haven't seen really good outcomes in my. Well, the clients that I see with any injections really shockwave sometimes, but very rarely is it a game changer in terms of, okay, it's really, really significantly reduced symptoms in there. Back to sport or whatever. But as you've mentioned, it's, it's all about load management. That takes time. If raising the capacity of attendant is just like any other muscle or something getting stronger, it takes months. It's, it's can be quite a slow patient process, which a lot of people and a lot of runners especially don't have. Yeah. And I think like in your practice, for example, you know, if you, they're being prescribed a really good strength program, there loads of monitor and you throw shockwave in, you know, that's very different to what's in the literature. The literature either does shockwave only and nothing else or shockwave and eccentrics and nothing else. There's no education. There's no load management. There's no self management strategies provided to the person, there's no, you know, that they don't even get told why their pains being a problem. You know, so I think what we do in clinical land often is very different to what's done in a lot of studies because, you know, I don't think it's very common. Why I don't Yeah, I don't think it's very common that someone just gets yet shockwave, they would hopefully get shockwave in a good exercise program or that, you know, and that that isn't studied. It's I think the only when the studies in shockwave use exercise, it's only eccentric, everyone just uses eccentric. And we know that eccentric is inferior to good loading anyway. So I, yeah, I think the clinical judgment on that for that person that is complex. And the other thing is that complex person that's tried all of those things, they get excluded from clinical trials. Because if you've had PRPs and stuff, you're not allowed into clinical trials. So We don't really have a lot of evidence over how those really complex people go. And that's why, yeah, you do have to use your clinical judgment, I think, to figure out how you're going to manage them because they are, they are tricky. Yeah. How about like management of flare ups? Because people who have chronic tendinopathy can experience like, you know, three or four good weeks seeing improvements, and then all of a sudden maybe they've done something wrong, or maybe they've, um, had a change they thought was safe, it really wasn't. And now they've experienced a big increase in symptoms. Do you have any advice or just general advice for flare-ups for tendons in how you can help these people? Yeah, I tell them to expect flare-ups and I say if they're not gonna get the odd flare-up, they're probably not pushing close enough to the brink. Ideally, the flare-up is only relatively small because if the flare-up is too large, then you've probably had a huge overload in the programming. And there's probably been an error there, but the flare ups are quite normal. I always say to people, expect your Achilles recovery. If you scored your pain every day to look a bit like a, an ECG, because it's going to be, you know, up and down, up and down, up and down. But the overall trajectory of that line will be better, but you'll have days where it's better and worse, and especially in the early phases, it's quite common because you'll have. the early phase where you're like, Oh, I'm feeling good today, I'll do extra and then the next day you feel a bit worse. And then so and then because you feel worse, you do a bit less, so you might feel a bit better. And then because you feel better, you do a bit more. So yeah, I expect this undulating sort of pattern of recovery with the tendons. And that's quite normal. And as long as people know what to watch out for, they're quite good. So if we're talking about that sort of symptom diary that we mentioned earlier, I would say that as far as symptoms, If you're, if you go for, say, a run on a Monday, like, let's rephrase if you had symptoms in your Achilles on Monday morning, and they were a four out of 10, and then you went for a run. And the next morning you woke up and your Achilles stiffness is a six. Okay. You've done a run. You're probably a bit sore. If your symptoms are worse that day, you don't go for another run that day. It's a no brainer. You've, you've flared it up. It's recovering. So no running on the Tuesday. If on the Wednesday you wake up and your Achilles is back to a four out of 10 for the stiffness in the morning, you've, you've bounced back. So you had your flare up and you've recovered and then you go for another run. If you massively overdid it on the Monday and then you woke up on the Tuesday and it's a nine and on Wednesday, it's a seven and on Thursday, it's a six. You're not running on any of those days, but on Friday, you're back to a four. You can probably reload the tendon, but you'd need to reduce the volume of what you did on the. Monday, because clearly whatever you did on Monday was way too much. So I think flare ups are pretty normal in the recovery of a tendon. I think they're expected. I do say to people, tendons are a pain in the bum because they do take a while to get better, but at the same time, they're also more forgiving. If you overload a hamstring tear and you're reaping a hamstring tear, you're back to day one. If you overload an Achilles tendon, you might lose a couple of days. But that's it. So they, they are far more forgiving. So you can push them a little bit more than you would if you're recovering from a muscle tear. I think that's a really good reminder because often people can go through six weeks of rehab and their symptoms calm down and then they overdo something. They maybe get overzealous or keen. And symptoms flare up back to where that flare up or back to where those symptoms were day one and they think they've lost six weeks and they think they're back to square one. Really good to remind people you're nowhere near back to square one because your strength that you've built over those six weeks, that accumulation, that's still there. It's just to structure sensitivity. It's just sensitive. It's not weak and you'll bounce back a lot quicker and can continue moving forward. Like you say, that long-term trend. And a few other points you're mentioning, hopefully these flare ups, just little bumps instead of big fluctuations, because our training plan itself is structured in a way to avoid those massive fluctuations, but try to learn from every. Blip try to learn from every little change in symptom to make future decisions to better, uh, learn and understand. And hopefully that doesn't, that same mistake doesn't keep happening over and over and over again. And then very importantly, you. not only learn, but then identify that long-term pattern, that long-term trend. So, um, some very important points there. Um, as we wrap up, where do you think this is heading? Like in terms of keeping your eyes on the research and, you know, participating in the research itself, where do we see ourselves in the next couple of years? 10 years or so, where's the focus being drawn towards in terms of tendinopathy management? Yeah, I think there's probably three big focuses. And probably the biggest one, and probably the most important currently, is we've just developed a brand new outcome measure for the Achilles. So the visa or the Victorian Institute of Sport Assessment of the Achilles has traditionally been the outcome measure that was used. But it's not that great. So there's a there's a brand new outcome measure called the tendonopathy severity assessment of the Achilles. And that's published in two parts. The first part is in the Journal of Orthopaedic and Sports Physical Therapy. The second part is in the British Journal of Sports Medicine. And this is a brand new way to quantify how severe someone's Achilles tendon pain is. So as opposed to the visa, which was not as accurate, this is far better representation and a lot more consistent. So we're going to start seeing, I think, a little bit more accurate data coming out from trials because the main outcome that we're using is better. So that's the first thing is we're gonna get better data out of any trials going forward, because we're gonna have a really good idea of exactly what loading these people are doing, exactly how much physical activity they're capable of and how sensitive they are when they perform loading, which are all really important things in Achilles research. So I think that's the first thing. I think the second thing, I'm really lucky to be part of a large group that has done a lot of investigation into the mechanisms of pain in people with... Achilles and other tendinopathies. And what's so interesting in the tendons is that tendons don't have the same pain responses and pain mechanisms as we see in other chronic conditions. So if we compare arthritis to tendinopathy, they're so different. We see all these systemic central sensitization changes occur in osteoarthritis. They just don't appear to be present in the Achilles and, or other tendons. And I think part of the reason for that is that. the Achilles is a, well, the tendons are different. They warm up. The more you do, you feel better. And the pain will go away provided you don't aggravate it too much. Whereas, you know, arthritis pain tends to stick with you constantly irrespective of what you're doing. So the chronicity is a little bit different. But why that's important is that, you know, we're gonna target our interventions a lot more at the localized tissues. So we're gonna work a lot more on calf, Achilles and all those structures. as opposed to going down the route that they have with low back pain, where there's a lot more central, um, targets. So things like the cognitive functional therapy and stuff like that wouldn't be probably that common sensical in the Achilles tendon group, which I think is really important. So we've got a much clearer, um, treatment strategy. And then thirdly, I think the biggest thing that's going to become or keep becoming really prominent is that it doesn't matter what you inject or do to the tendons. If you don't get, the physical function capacity into the tendon, you're not gonna have any success. So I think that we're really moving away from the era of eccentrics. We're no longer using eccentrics as our gold standard in all of our treatment interventions. And I think that's really exciting because, you know, eccentrics aren't what we're doing. We know that the evidence doesn't support them being the best thing for tendons. So we wanna move away from them. And I think, yeah, we're gonna start seeing a lot more clinical studies. representing what we actually do in our practice for these people of good strength and conditioning principles, good load principles. And I think that's really exciting in the tendon space. So just quickly on that, just the eccentrics itself, like helps load the tendon, but doesn't do much in terms of functionally restoring capacity. Cause we don't have that concentric phase. Is that right? Yeah. So it was actually shocking. We did a big review where we looked at all the studies that had done exercise rehab for the Achilles. So every trial that had done exercise interventions for the Achilles, the Alfredson's Eccentrics program, the Silbernagel protocol and some others. And when we actually looked at the markers of strength, so number of calf raises they could do, the isometric dynamometry, isokinetic dynamometry, all these other markers of calf function, after you'd done about a 12 week course of exercise, they didn't change. So we had people who were in an eccentric program doing 180 eccentric heel lowers a day. And after 12 weeks, they couldn't even do five extra calf raises. That's ridiculous. And in clinical practice, that's not what happens. If you give them a good exercise program, their capacity improves. They can do more calf raises. They do get stronger. We see that in our patients. So I think that's something that's really exciting is that we're moving away from these. interventions that while they might be somewhat effective at reducing symptoms, they're not very good at restoring that capacity that athletes and other people need for good levels of function. And I think we're gonna start studying that a lot more intensively in the next sort of five to 10 years, because we're recognizing that while the programs might be good for pain, they're not very good for tissue capacity and function. So there's a lot more exciting research coming out in that space. Great, Miles. Um, are you active on social media at all? Are you like posting anything to do with tendinopathies and achilles that people might follow if they're interested? Yeah. So I'm on, um, X or what was Twitter? Um, and it's just miles underscore physio. Um, we are doing a big study at the moment in our new outcome measure to try and get as much diversity of responses as possible. So we've got a big drive that basically anyone that has current or past achilles tendon, we're trying to get them to do this survey. It only takes five minutes. Um, to get, you know, some idea of how people's presentations are with their tendinopathy. So yeah, you'll probably see that first and foremost on my, my social media at the moment, but, um, yeah, that's probably the best platform for all of that is, is X. The deadlines, how long are you continuing the survey for? Uh, the survey will be open until early June. Okay. Excellent. Well, people could go there because I think this will come out in about. I don't know, maybe four weeks time or so, um, maybe three weeks. So plenty of time. No, that'll be, yes. I'll definitely, uh, put those links in the show notes for people to follow you. And want to thank you for your time. I want to thank you for your, uh, time and energy into the research and understanding around tendinopathies. It's, uh, still, you know, I think there's a lot of misguided clinicians and people out there that are just confused about what to do. And. some practical ways to manage their chronic tendinopathies. And I think we've illuminated a lot of methods that might be a lot more effective than others. And, you know, just coming from a research background, I think it's really nice to hear. So thanks for all the time and energy you've spent. I know publishing papers isn't easy and it helps a lot of people. So thanks for coming on and sharing. No worries. Thanks so much for having me. If you are struggling to overcome an injury, you can jump on a free 20-minute injury chat with me which you can book through my calendar in the show notes. While you're in the show notes, elevate your running IQ by jumping onto my free email list so you can receive material to help rehab your injury, lower your injury risk and increase your performance. If emails aren't for you, consider my Facebook group, Instagram and YouTube channels. And remember, each insight you get from these resources brings you one step closer to your next running breakthrough.