601: Dr. Seth O’Neill: Achilles Tendinopathy: Diagnosis and Treatment

In this episode, Physiotherapy Lecturer and Tendinopathy Researcher, Seth O’Neill, talks about tendinopathy. Today, Seth talks about his interest in tendinopathy, and his presentation at the Fourth World Congress of Sports Physical Therapy. What is the warmup response? Hear about Seth’s diagnosis framework, the appropriate use of imaging, rehabilitation, and get his advice to his younger self, all on today’s episode of The Healthy, Wealthy & Smart Podcast. Key Takeaways “You’re going to have some discomfort with these exercises and that’s okay.” “Get your diagnosis right in the first place.” “Say yes to things when you can. Push yourself and you’ll get there.” More about Seth O’Neill Seth is a Physiotherapy Lecturer at the University of Leicester whilst also maintaining clinical work. He has a PhD on tendinopathy, within this Seth has identified prevalence rates of tendinopathy in UK runners and developed a greater understanding of risk factors surrounding Achilles tendinopathy. His later work has completed a more in-depth analysis of how tendinopathy affects the Plantarflexors. This has focussed on how the strength and endurance is affected and which of the Plantarflexors is most involved. This work has highlighted the involvement of the Soleus muscle in human Achilles tendinopathy. This has led to the further work related to Calf injuries in sports. Whilst Seth’s focus is on the Lower limb he maintains a strong interest in all MSK conditions. Seth feels passionately about supporting Physiotherapists to undertake further research either as standalone projects or MRes’s or PhD’s. Seth is currently examining tendon structure and changes that occur during health and disease along with Biopsychosocial interventions for tendinopathy and LBP and developing an international database of calf injuries. Suggested Keywords Healthy, Wealthy, Smart, Tendinopathy, Physiotherapy, IFSPT, Injuries, Recovery, Rehabilitation, Diagnosis, Exercises, Resources IFSPT Fourth World Congress of Sports Physical Therapy To learn more, follow Seth at: ResearchGate: Seth O’Neill Twitter: @seth0neill Subscribe to Healthy, Wealthy & Smart: Website: https://podcast.healthywealthysmart.com Apple Podcasts: https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify: https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud: https://soundcloud.com/healthywealthysmart Stitcher: https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio: https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927 Read the Full Transcript Here: 00:02 Hey, Seth, welcome to the podcast. I'm so happy to have you on. 00:06 Thanks very much for having me, Karen. It's great to be here. 00:08 Excellent. And today we're going to be talking about tendinopathy, maybe specifically Achilles tendinopathy. But before we get into that, I just want to let the listeners know that you're one of the amazing speakers at the fourth World Congress of sports, physical therapy taking place in Denmark at the end of this month, August 26, and 27th. And you will be talking about tendinopathy. So before we move on, I would love to know why. Why tendinopathy? How did that become sort of your specialty, your interest? 00:46 Yeah, tricky to sometimes answer these type of questions, really. But I've had tendon problems myself. So being active and sporty, I developed an Achilles problem, number of years back when I was a relatively junior physio, and we didn't really understand how we were trying to manage these things. And that took a long time to settle down. So that really sparked it off. And then not long after I developed poutine. And problem as well, my Achilles from wearing sorts of constricted footwear. So wearing wetsuits, boots, for a day, with doing wakeboarding and stuff. So developed the interest because I had the problem myself, which is probably the answer for most people, I think, with how we ended up specializing in one thing and went on to look at Achilles problems and differentiating these out as part of a master's dissertation project that did, and then still had some clinical questions I wanted to answer to help me understand how to manage people better. So I did my PhD in it as well. So yeah, it's one of those sort of sorry, stories of a while me. 01:50 And before this sort of deep dive into the literature, and a master's in a PhD, and maybe even during that journey, are there any cases that you worked on that you were like, Man, I would do it so differently now? Because I'm sure I mean, I know I have that every physio listening to this can probably relate to this. But where have you learned from your mistakes in relation? We'll say, we'll stick to Achilles tendinopathy. Right. So in relation to Achilles, tendinopathy, so that the listeners out there can be like, Oh, I think I just did that. And maybe I'm gonna change my mind. Yeah, 02:28 yeah, we're at a good number of these things, including not too distant past as well. I think like everyone, we're always learning. And we've all just got to admit to mistakes and where we can benefit and do better. So I think my early ones, particularly were around differential diagnosis, getting or missing things that were going on as well. So remember, one relatively young lad with an Achilles problem, sent him off doing Alfredsson Essentrics, this was probably 2001, something like that, came back loads loads worse and had this funny swelling around the back of his money, hola. And I was like, never seen this, this is rare, and didn't know what was going on at all. So sent them off for an MRI scan via our consultant at the time and came back with an accessory soleus, which is where part of the muscle is low lying and actually sort of fills where cake is fat pad is back in money can cause pain and be symptomatic. And the old school approach is to just go in and cut it out. So the surgeon is booked out and ordered and dusted. But I totally missed it. The first time I saw him, I don't know whether the swelling was there at that point, or whether I triggered him off or made him worse with the sort of rehab. So possibly, but also then I've had a couple of people during Alfredsson regimes that have actually ended up with ruptured or partial ruptures, partial tears, as a consequence, and then yeah, you end up sort of feeling terribly bad that what you were doing to try and help someone's actually caused a significant worsening of their function and symptoms, and they even had a patient with this happened last year, who will go and try and write up as a case study because it's really interesting management program afterwards with scans and stuff, but ultimately, they have big problems. 04:15 Yeah, it does. It happens to us all. And how do you from that? You can, you know, we can edit this out if you don't want to answer this. But how do you deal with that from sort of the mental standpoint of oh, shoot, like how do you mentally deal with that? Because I think that when that happens, it can you start to question why am I doing this? Am I the right person for this job? It can lead to burnout, that stress. So how do you manage that from a mental health standpoint, when things like this happen? 04:53 I think the thing is often as a junior therapist, you beat yourself up more because you sort of think I should have known I should sort of understand that, I think as you get more experienced than me, I'm 22 years 23 years qualified. Now you have lots of experiences like this and have to pick yourself up from them. And you just start to accept that that is like that's normal, whatever area of work you specialize in, or work in, whether it's physio, or even being an accountant or something, mishaps in things that you can learn from learning experiences happen all the time. And it's really just then taking what you can from it and developing and getting better. And when you have a bit of a boo boo happen like this, we tend to remember it and you never then miss it in the future. I mean, a couple of examples that I had in the past would be like federal stress fractures wasn't even on my diagnostic radar back when I was a junior therapist. You don't get taught at university and stuff, and then you sort of you miss one. And it's like, right, never missed one again. Now, it's always high up on your index of suspicion. So it's really just not trying to beat yourself up, realize it's a learning experience and identify what you can do. Going forward with it. Part of your CPD of your reflective practice that we're all encouraged to do and often do do but not formally. So yeah. 06:14 Yeah, great advice. Okay, now, let's get into the meat of the podcast here. So what we'll talk about is kind of you mentioned it differential diagnosis. So we'll talk a little bit about that, and then go into some possible treatments and, and outcomes and things like that. So let's say someone comes to you, with posterior ankle heel pain, they haven't been to their GP or to the orthopedic yet, because that happens a lot. Here in the US, I'm sure it happens a lot with you in the UK, as well. So I will hand the mic over to you. And you can maybe walk us through your differential diagnosis framework, what are you looking for when someone comes in with that? 07:03 So the first thing, I think is, as everyone already knows, is not to take whatever the previous diagnostic decision was, if they have seen someone as well, I make sure you do your own workup, because let's face it, we all make mistakes as well. So I'd always look at them with fresh eyes and not go with the the original diagnosis and make my own mind that the three big things that mimic Achilles tendinopathy really then are related to posterior ankle impingement. So in order to try going on, whether it's a bony impingement or not, and they're the ones actually see quite commonly that have been mismanaged that add a cricketer, recently, his professional cricketer, who had been sent from their medical team in one of the counties in the UK, or England, I should say, and unfortunately, that miss that he had a posterior impingement, not an Achilles problem and been trying to manage them and manage him using some invasive procedures, and actually scan and everything else when I scanned in, but absolutely pristine and fine. And that's the one thing I do come across time and time again, it's just people miss the impingement side of it, and normally, the x, so aggravating factors and easing factors that the patient will report to you if you listen carefully, and inquire, will be very, very different. It'll be a totally different set of positions, not about tendon load, it'll be their ankle position. And being in that plantar flexed position that's relatively simple and straightforward. But again, it just, it commonly crops up other common or relatively frequent presentations, then we'll be around several nerve. So one of the branches of your sciatic nerve runs on the lateral aspect of your Achilles, we just want to simply look at something like a straight leg raise with a neural bias for the inverter area. So you do inversion with dorsiflexion. And if movements like that provoked the pain, that's not normal for a tendon, it would normally only hurt when you put larger loads through it. And energy storage demands not simple structures, except in very highly irritable cases. But you can only determine that clinically. So they're the two big things that the third group then is other localized tendinopathies. So to be honest, posterior, or per Nei, which I think you guys call something different in the States. What are the perineal inverters of the foot? We always have problems when we teach anatomy with our students, if they use an American app, it gives it a different name. I forgot this. But anyway, so yeah, so just looking at the differential between those other tendons. So patients may refer and sort of suggest its posterior heel, but actually it's in front of the Achilles. So it's normally relatively localized pain and there's lots of debates on social media about what happens when you get diffuse pain in that area. diffuse pain is really quite rare in this area, and I do see a lot I still work clinically as well as work in that university from a research perspective and I do a lot of consultant work in sports. and wider as well. And we just don't see widespread pain in this region particularly. And the evidence really suggests that tendon off the Achilles particularly will be localized pain. It doesn't sort of spread out. But there will always be some exceptions, I'm sure. 10:15 And it sounds like from what you're saying one of the other really important things is that subjective interview. Yeah, right. So what questions are you honing in on? What are you What do you really want to know? 10:29 So I'm actually take a leaf out of Peter O'Sullivan's approach for back pain and look at the patient's story. How do they describe this originally starting? What's gone on with it from then? And what are their thought processes around that. So we really look at the whole patient, not just that the mechanical bio sorts of components here, but then our teas into the aggravating and easing factors. So where the pain is what makes it worse, what makes it better how long it takes to come on, often expecting a latent response. So the pain is not necessarily happening during this activity, it will be a latent flare up later. Although you'll sometimes get a warm up response during the activity as well. So we're looking for these hallmarks. And what we should pick up in the subjective is progressive tendons stress. So the example would be walking for the Achilles versus running versus hopping or jumping or London being progressive load, the higher you go up that ladder, the more it will flare them up or make them sore. And then what we're trying to do is look at the sin factor, then if you guys use that, as well, so severity, irritability, and the nature, but the irritability is key, the more irritable these are the lower level, we're going to start your rehab. And a lot of this subjective really helps guide our initial intervention program. But of course, on top of all this, we've got to consider the patient and the complexities that we get from our psychosocial component. And we've just had a sort of paper out with Neil Miller, and the group from Glasgow on biopsychosocial approach to tendinopathy. This the icon statement from the international group, that Karen Silverado that you mentioned earlier, and that's really looking at the psychological factors and social factors that are relevant for tendinopathy. Because like any musculoskeletal condition, the person's important, it's not just the the localized tissue that we sometimes can get overly focused on. 12:25 Absolutely, I'm preaching to the choir there. Now you had mentioned something in that, just now the warm up response. So can you explain what that is for the listeners in case they're not quite familiar with that? 12:38 Yeah. So this will be the person that will go for a walk or a run, or whatever their activity tennis, squash, whatever it happens to be, and they'll find it sore initially, and then it will get better, it feels better during the activity. And we tend to see this happens when they've sat for any length of time, if they're an inactive person, they'll get the same response then so the first five minutes of getting up having sat for an hour or two will feel sore, and then it gets better. And this is particularly common in the morning, where patients get up. And they say I was sore for 10 minutes until I've walked downstairs, made myself a coffee or had a shower. And then I feel better ready for the day. And that's typically what we see. So this sorts of pain that is focused around starting an activity when you've been inactive for a period. So that's 13:27 excellent. Thank you so much. So going back to our fictional patients here, they come in, they've got sort of posterior ankle pain, you've ruled out posterior ankle impingement, sural, nerve, local tendinopathies. And now you're really thinking well, given their subjective exam, given the little bit of objective exam that I've done, I think that we're dealing with an Achilles tendinopathy. Right, so you've kind of made that diagnosis. Now, what happens? 14:03 So once we've determined that we think it's an Achilles problem, we just want to make sure that's the case. And the best, most accurate, sensitive clinical test at this moment, whilst it gets a bad press is actually the site of pain. So asking the patient's point to it, or you look at then gripping it and looking at how Patri pain, they should put them to touch that tendon. If it doesn't, then we perhaps not dealing with an Achilles problems that would set up some alarm bells. The next thing then is to work out what sort of tendinopathy they have. And within that, what I mean is there's this sub entities, so there's different groups that will cause Achilles pain. So you could have a parent teen and disorder, like I mentioned, with myself earlier, which is essentially inflammation of the sheath around the tendon a bit like you get with the equivalence, Tina synovitis in the wrist or thumb is that same process, and that probably needs to be managed very differently because that's about friction of the sheath against the tendon. And so we've managed differently, we'd also then consider insertional, tendinopathy versus midportion, the risk factors, and some of the subtle management may differ. And as part of that, often we'll talk about trying to reduce compression of the tendon, which is what happens when you're in a dorsiflex position where the tendon will swash against the superior aspects of the calcaneus. That is had probably inappropriate interpretation from lots of clinicians, where they've heard about it and then say, we should avoid dorsiflexion. And patients then get told to avoid it. But that is forever. And of course, dorsiflexion is normal. So we've got to make sure we have encourages it. But in a highly irritable case behind center factor, we'd avoid that in the initial phases, or reduce it. So might use a heel wedge, so midportion and insertion burn, then with the mid portion, we're trying to look at whether it's really related to the Para tienen there's a potential of a partial tear. Or you can get these other disorders, which we have academic disagreements about, called splits, where actually, if the fibers run sort of longitudinally, you can get a pull in a part of the fibers. And they're called longitudinal splits, or occasionally get a flat tear where the back of the tendon or deep section and tendon pulls off. 16:18 Clinically, for me, they are much harder to manage. And they're the ones that I have, certainly in the last 510 years, made much worse, both symptomatically, functionally and also structurally. And they're the ones I think we need to be cautious about how we look at differentiating those out clinically is on subjective, again of how did it start? Was this a onset that you develop during a sporting activity or a activity a functional activity, like crossing the road and stepping up a curb? Or going down stairs or making a bed or something? Or did it involve whatever else or did it just come on gradually, you were sore the next day, after you did a long walk or a long run, that's more akin to normal typical tendinopathy being a generalized process of degeneration with some inflammatory elements that we sort of know and love as tendinopathy. But these sub entities seem to be very different, I think for management, the problem with all the research, nobody splits them out. So all the research doesn't differentiate out these sub entities, they stick them all together. And part of this is why I think a lot of regimes have washed out, they they look like people get a generally good response, some get worse, some don't respond. But generally about 70% of people get better. I personally think if we can look at these different entities, we will probably improve our rehabilitation. And Karen silver novels work I've forgotten now is going to go ahead and first author a bit. So I apologize. Currently the senior author, they've looked at actually identifying clinical groups, so psychological. So the profile group, a structural group, and more of a biomechanical sort of weakness group. And that's, I think, got some legs to go forward with how we might look at our patients in the clinic. And remember, if there's one more group, there is one more sort of sub entity which is plant Taris, induced tendinopathy. So typical presentation will be middle section pain, a little bit higher than typical midportion. And they may find that actually been in plantar flexed or dorsiflex positions when contracting the muscle, and therefore loading the tendon actually hurts. And that's because the RENNtech muskies work that he's done has shown that you get some compression of the plantaris tendon against the Achilles tendon, it seems to then set up a tendinopathy based on compression. So we can identify that clinically with palpating, the medial side. But ultimately imaging is probably then the better way to identify it. But it doesn't mean they need surgery, either. That's the other important message for you to take away from it, they've always had that plantaris. It's always been there for that person's life, they've developed the symptoms for whatever the reason, and they will probably respond to normal management, but maybe with some modification to load in in dorsi, flex or plantar flex positions. So we work in the middle a bit more initially until we're starting to settle and improve. Certainly in my clinical work, they will settle just as well as any other area does. But of course, with a lot of the research people are seeing tertiary sort of work failed, we have failed rehab with multiple people. And then of course, they're more likely to go on to surgery. So we've always got to interpret the literature a little bit with caution based on the populations that the research groups or whoever is writing the paper actually see and deal with clinically. 19:45 Yeah, that was a great overview. Thank you so much. Now that you mentioned imaging, so can you explain how you explain to the patient Do you need imaging? Do you not need imaging? When it comes back? Let's say an MRI comes back. And they're all out of sorts, because Oh, the doctor said, I have damage to my tendon, how am I going to fix this? Right? So how do you deal with that? Because if that is what happens, and then people say, well, when we're done, should I get another MRI? So that I can see the tendons back to normal? So how do you respond to that? 20:29 So that last one I'll deal with first, that is that actually, you're probably going to see some residual changes in the tendon that will take a long time to settle down. And this may be akin to scarring. So when you put your hand you end up with the scar afterwards. And that actually, what we're seeing on the imagery at a later date may be similar to that scoring process. And also reminding them that attendance is very slow to remodel and recover. So really, we're talking about imaging a year plus, if we want to look at it. And it doesn't matter what the tendon looks like, it matters, whether their symptoms and their function and good early on, I would have a different conversation in an elite sporting population, though, where actually, we know that attending that has structural changes is seven times more likely to develop symptoms the next season. And actually, I would probably then want to be changing the tendons structure. But again, that will be a discussion I have with the medical team, perhaps not the athletes so much, because we don't want to, we have to be very careful about the psychological impact of our words with our patients. And this is why imaging has had bad press over a number of years. Because it's often given to patients and they get told, Well, you've got tendinopathy, you've got big tearing there, there's loads of fluid and inflammation and the patient's like, well, I need to then rest until it settles, I need to sort of get this better, and how the hell is it loading exercise is going to help me get better when that's actually what's triggered it. So they're the clinical challenges that we have to explain in terms of the first phase, when we do the imaging, I simply try and D threaten them with it. So say, Look, this is typical of what we'd observe for somebody with tendinopathy. So that is tendon pain that you've presented with. This is not out of the ordinary, this isn't something that's particularly severe, assuming that that's the case based on the imaging. And I've also with MRI identify that it's actually a poor technique to look at collagen. So all we're going to see is high signal, really, it's very, very hard, you need to be have an excellent scan and an excellent radiology radiologist to really examine collagen fibers with it. So it will tell us how big the tendon is. And it will tell us how much fluid there is in there. But we know that that doesn't have a strong relationship with pain. And this is again, part of the reason why we wouldn't want to do it down the line say much. Having said that, again, Karen southern handles group, it's got some lovely papers that have come out that showing structural change does occur with functional resolution and improvement in symptoms. So we've got 42 different research groups in the world at the minute the Australians have often said we shouldn't be looking at imaging, whereas actually Karen's group and I think where we're taking it in the UK is that we should it has a use. But we've got to be very careful with that interpretation. And we certainly see changes in tendon structure as we have patients, we don't need to see it in order to get resolution. But that's because structure doesn't correspond to what's likely to be the key chemical factors in the tendon that are actually what's triggering pain. And we know there's lots of different chemicals involved in tendinopathy. So it's sort of trying to tie it all together. My reason for imaging, I use imaging in practice most of the time is to help we lay patients fears because often they're concerned about the risk of rupture. And this has come out in Shama core lifts qualitative work on Achilles patients. So by imaging, I can actually say, Look, your tendon has plenty of healthy tissue here. This, as best we can say, at this moment in time, is a very low risk for rupture is no higher than a normal person, because there's the same amount of tissue as a normal person would have. 24:06 Where we then have to be careful is where we find that's not the case. And we've just been doing a big longitudinal study in premiership rugby in the UK. Looking at this to see about how that changes. And Matt, who's doing a PhD with me, is going to be analyzing and looking at that data. So Matt Lee is head of medicine at Northampton saints. So Matt's got a big bit of work to determine whether really it ties in and whether we can predict who gets more symptoms, how that ties and, and they don't leave those, but we need to test that and so we're going into it to see probably, but yeah, good use, I think for imaging but not longitudinally imaging for most of your patient group. And it's not necessary and most of you patients you've got coming through your front door for a normal practice. But where there was a sudden onset of pain during activity, and they don't respond Do a six week sort of period of intervention or 12 week period, that's when I would want to image to see what I'm dealing with. Or where there's overt metabolic changes in the person. So adiposity, so high lipid levels, high adipose levels, so the waist circumference, and diabetes, then we want to just make sure they've not got some underlying problems, like, sort of gout that's going on or pseudo arthritic complaints. So yeah, that's where we're going, we might just step up a little bit and maybe consider blood tests as well. 25:33 Great, thank you. Now, let's move on to some treatment options. Right? So we've we've done the differential diagnosis, maybe we got imaging, maybe we didn't, we've, we've ruled everything out, we're pretty confident we've got an Achilles tendinopathy, I will leave it up to you, if you want to say well split it from like, you know, lower to sort of an upper you can, I'll let, I'll leave that in your hands, and how the rehab may be different. 26:05 There's no magic. So that's the first thing. There's no exercise, it's better than the other. It's about understanding the basic principles of rehabilitation here. And this is really what we do, I think, for all of our patients we ever see during a normal clinical role is going well, what do they want to do? Where are they now? How do we bridge that gap? And that's essentially what you're trying to do with your patient is, what's their functional ability at this moment in time? What do they want to do going forwards and coming up with a strategy to try and progress through that? Making sure that that allows for appropriate timescales. So tissue recovery, after exercise, if we're trying to adapt muscles, and muscle strength, which is often one of our big aims, we need to allow appropriate timescales. So 12 weeks plus, rather than expecting rapid changes quickly. So what that looks like in practice is going well, initially, we're going to start off with some form of loading for the Achilles tendon. Now, I would use a very, very isolated exercise, because you can compensate by offloading us in other muscles if we do more complex tests often. So an isolated simple exercise will be a heel race, you can't cheat, you can't use your quads and glutes to compensate, you have to use your calf and it puts stress through your tendon. And there's a nice work with Steph Leser, there's just to out on a systematic review, we're just sort of tweeting about earlier today on tendon material properties and how loading modifies the tendon, and part of what we want to do is improve the stiffness of the tendon, because with the Achilles tendinopathy, it will be less stiff. And that's generally pretty accepted. So we want to make it stiffer. And loading does that the loading needs to be progressive in nature. So we use the symptoms to determine that current simple novel, initially pioneered the pain monitoring model. So looking at how sources during the activity and afterwards, getting an appropriate level of discomfort that the patient can tolerate, doesn't impact their function and making it harder. So something like bilateral heel raises if somebody's really Niggli and saw progressed to a unilateral heel raise, that's about four times body weight through the Achilles tendon. For a bilateral erase, again, depending on the modeling method that's used Josh Baxter in the state system, some nice work on this in his lab, and he's got a lovely paper with Karen as well showing exercises that increase tendons stress. And that's a really good paper for your listeners to have a little read off to look at how to progress or to give ideas of exercises and how they would progress through that. Running, for example, be about five to six times body weight for the Achilles per step. So what we're trying to do is go well walk ins for running six, how do we cross that boundary and use other exercises, or just add external load on to heel race, which is probably easiest way. And that then allows very isolated, monitored exercises. At the same time, I would always use walking or running the same period of time, we wouldn't withdraw them unless we're very, very slow and very struggling. So we'd always use that. And in most patients, if we're not talking athletic, we don't need to use plyometric training jumping up in and stuff we can use walking and running, if necessary to do that. But the more elite athletes, I would always be looking at plyometrics. So hopping jump in London, whatever it happens to be accelerations decelerations off tangent runs, they all increase the stress through different fascicles of the tendon. And that's I guess one of the aspects we can consider that's not been researched yet, and it's where we're going with our work is how we might bend the knee or straighten the knee or rotate the foot to isolate the stress through different sections of the Achilles that correspond to where on imaging we see the degradation. So if we ever want to remodel the tendon, we also need to Reese stress To the tendon at an appropriate threshold, that needs to be 85 to 90 or more percent of your maximum voluntary contraction. And let's face it, we have never done that because most rehab doesn't quantify strength. So I'd always measure spend 30 on a lot of you guys, I think in the states have access to isokinetic devices within your clinics or in local clinics, or other force measurement devices. And I, Scott Morrison's, got quite a lot of sort of workout suggesting how you might be able to do this with a handheld dynamometer, then there's methods we can do with that, or even a set of bathroom scales, to actually utilize a measure strength to give a patient a marker. So our normal data in rugby and football on large cohorts is twice body weight is normal. And we've got similar in endurance runners, our patients are typically one and a half times the weight. But that means doing a heel raise with just their bodyweight will not strengthen them significantly. And that's where we lack we have been our rehab has to be a lot heavier than we've often done in the past. So yeah, so in a nutshell, bilateral raises unilateral progressing through I don't use isometrics early as a method for pain relief, because the evidence substantiates it's not actually that good for pain relief, unless patients find it when the fork which case use it, the heel raises. good warm up response anyway. 31:24 Perfect. Yeah. And in the states do a lot of places have isokinetic testing? I don't know. Sorry. I don't I don't know about that. Even here in New York, I don't think you know, outside of like the larger systems. I don't know that a lot of individual physical therapy offices have that i i do have a handheld dynamometer. And I'm lucky enough to be friends with Scott Morrison. So he was able to kind of take me through and and how to use it. And but it's sometimes this setups can be a little complicated, especially if you don't have an office, if you go to people's homes, how do you stabilize one end and use the other end, and I've come up with some interesting options? Yeah, it's work. I use a seatbelts, I have chains, I have like this, the green, you know, the green stretch strap. Yeah, that with all that I started using that, because it doesn't give, you know, it's pretty, it's pretty good. So kind of it kind of along the line of a seatbelt, you know. So I started using that instead of using even some chain link, I found it to be a little bit easier, a little more gentle for people on their phones, 32:49 strap ratchet strap that you might use on a roof bar. So roof rack, you might actually use that strap and those type of straps can be very good, especially if the wider if the narrower than it hurts the person's knee when you strap it on top. But ultimately, I like it because we can showcase that they need to do strength work because they are weak, more data to give them when you haven't got that opportunity, it's really just sort of giving them this sort of step sort of wise approach to go while you're here need to be there, we need to progress through this and you then just target an exercise that is tolerable, but is sort of getting a little bit of reaction afterwards for a short period. So I've said bilaterally raises unilateral, unilateral with weight, or progressive forwards. And if you're a physio or PT that likes lots of different exercises, give them a dozen, that's fine. But if you're like me, I'm very simple, I just give them one or two things to do really well to do very regularly. And what we avoid in that way is they don't do the things that feel comfortable and easy, because that's what patients generally do. And they're avoid the ones that hurt them because they think it's making them worse. But if we educate them that this is critical, we've got to poke it a little bit to stimulate the cells and improve muscle strength to help the muscle shock absorber for the tendon, which is our current understanding of what we're trying to do with rehab. Then we've got to actually sort of work very well in a bit of discomfort. 34:21 And you beat me to the punch that was going to be my next question is how do you talk to the patient about like, this is not going to be pain free, necessarily, you know, you're gonna have some discomfort. So you kind of beat me to the punch on that. But I think it's important that patients know that you're gonna have some discomfort with these exercises and that's okay. Because a lot of people have been told, I certainly I see it, I'm sure you see it their whole life if it hurts, don't do it. 34:47 Yeah. says and what you've got to explain to them and I often use examples of relatives that you might have had that have had a hip or knee replacement done in the hospital and how afterwards they have to bend it have to walk And actually, yes, it hurts when he gets better or if you've broken your arm and you're in a plaster how gently stretching out when you come out of plaster help to get better. And that's then normally enough to help people go. Yeah, I understand that I can see how that would help and I also then often just explain that as you do this and you get the symptoms afterwards that's the cells in the tendon excreting some chemicals that whilst it makes it a bit sore, they also actually be modelled the tissue. And what we're trying to do is wait the cells up to repair the tissue, wait, repair the tendon, but also improve your muscle as well at the same time. And we've got to stimulate it. It's no different from delayed onset muscle soreness if you go to the gym so that's the other one that are commonly used as the example then we'll turn them penis Dom's is this chap called William Gibson in Australia has done a whole PhD on delayed onset soreness, because it's tendons that you've looked at and connective tissue, not muscle fibers sarcomere itself. And his work I think is really pivotable pivotal with our understanding of it. So yeah, flip it around as Dom's most patients have had Dom's at some point in their life. Yeah. 36:11 Oh, that's great. Yeah, I love that. Well, I have to say, I'm gonna have to re listen to this a couple of times, even though I'm here, I feel like I'm missing things. Like you're speaking I'm like, wait, what? Wait, did I miss this? And we have to listen to this over and over again, because everything is so good. And I think thank you for making it so applicable to the practicing therapist. Because I think that there are nothing against researchers. But there are a lot of practicing therapists out there probably more so than researchers who depend on you guys to be able to to some disseminate this information in a way that is practical and makes sense. So thank you for that. Now, as we start to wrap things up, what do you want the audience to take away from our conversation today? What are some key points, 36:56 I guess the most important parts of monitoring and treating people with tendinopathy is just get your diagnosis right in the first place. Differential diagnosis gets a lot of bad press at the moment, I think on social media, and it's been wanting to sort of dumb down and go with just we've got posterior heel pain, but how I treat an impingement versus tendinopathy will be very, very different, you need to differentiate. And then you need to look at isolated tendon and muscle exercises that is progressive in nature. And I think the key message to physical therapists and physios is that we need to load a lot heavier than often we've done in the past. And by getting normative values for certain sports like we're doing at the moment will help guide what we should be targeting. And they have performance relevance as well when you're dealing with athletes. But for a normal patient, this is a difference between crossing the road quickly in front of the car that's coming in, versus actually ended up with the car getting a bit too close to you. 37:55 Got it? Yeah. And and I love that load heavier and looking at the normative values, because like you said, if running is five to six times body weight, and you're working with someone doing a single leg heel raise, just with their own body weight, that's just not going to be enough. Yeah, right, we've got to we've got to push them a little bit more to load a little heavier. So thank you for that. Now, Seth, where can people find you if they have questions they want to ask you or they, you know, they want to find your research, where can they contact you. 38:27 I'm not a huge one for pushing the sort of research out other than via Twitter. So I have a Twitter handle that we sort of use regularly. And we'll put papers on there and things. But I don't have technically got a website that's on my Twitter profile, but I don't update it. So I'm terribly slack and too busy to bother updating it and need to sort it out. But hopefully this next year, I have a bit more time. So Twitter's The best one is just Sefo Neil, but yo is zero, because there's already another stuff anyone in the world someone and then my other handle is Achilles tendons on there. And just so you all know, it wasn't ego thing. We set it as Achilles tendons, because we went on Twitter originally to recruit patients for our research because some cancer specialist at the University had suggested it was a really good way is terrible, because you need loads of followers to be able to recruit patients and actually get your message out there. It was great for networking. And that's I think the big thing with it. So I network predominantly and occasionally advertise research projects that we're doing now. I've got enough followers to actually get some patients through the door that way. But yeah, not ego because it just so we're clear, 39:33 of course, and we'll have links to those Twitter accounts in the show notes at podcast at healthy, wealthy smart.com. And like I said at the top of the our conversation, you are speaking a few times at the fourth World Congress is Sports Physical Therapy in Denmark at the end of this month, August 26 to 27th. So do you want to give a little sneak peek about what you're going to be talking about? At And what are you excited about for the conference? 40:03 So, myself and Karen Silva novel are going to be running a joint session for the British Journal Sports Med breakout on treating people with tendinopathy. So we're gonna do two sort of sessions of that. So replicate it. So hopefully, if you're interested in coming in, you can come in and send that and hopefully, it'll be nice and interactive, and flesh out some of the aspects we've discussed now, Karen, and then I'm chairing the session, which will be the session that I'm most looking forward to with Karen's there, who else have we got, I gotta get it right now. Michael Caja, and also Ben, Steph, Dakin, as well. So really looking forward to that. We're really nice to hear these guys talk because they are literally at the top of that sort of pinnacle of researchers and clinicians really worldwide. And then Denmark's nice. I mean, every conference, all I've ever managed to see is a little bit of Copenhagen. Because it's been sports Congress. And I normally dash in and bash out at conferences. So it's a little bit the same this time around. But I'm actually looking forward to seeing a bit of seen a bit of Nyborg. And also put two hours in the middle of the day for activity. And they've suggested paddleboarding. And whilst I dislocated my shoulder a week ago, or two weeks ago, it's my second time and I'm actually I was paddleboarding at the end of the week. So I'm hoping that there'll be a bit better by then and actually get out and have a decent paddle board and some exercise rather than just sat at the conference. So that's one of the things I'm looking forward to, and of course, enjoying a small beer with yourself. 41:40 That's yeah, it's a small beer. I look forward to it. And I'm looking forward to going in the summer, because I've only been to Copenhagen in February, and it is cold, and snowy and rainy, and all that stuff. So I'm looking forward to going in the summer. And just looking forward to seeing a lot of people that I haven't seen in a while. So that'll be really fun. And now last question, it's a one I asked everyone knowing where you are now in your life and in your career, what advice would you give to your younger self? 42:13 Oh, gosh. Yeah, it's a really hard question. For me. I always fancied doing research, but I was always put off because there was no ability to do it when I first qualified to do a PhD in the UK was rare in physio, and you might have been able to get a stipend which is 15,000, a year, UK, which actually quite peaker often they further physios as well. Whereas now I'd actually say if that opportunity comes up, even if it's a bit of paper, I take it if you can, because it does open a lot of doors as you progress forwards. And I would unlike other people, sometimes I'd actually say yes to everything. Generally speaking, when it comes to work, not anything else in life, to look at options that we can just opens doors, you get so many things that you don't realize where it will lead and you agree to do something and actually, certainly in these uncertain other things that are fantastic and change your career. So say yes to things when you can push yourself. And yeah, you'll get that. So read the next Roscoe put that. 43:21 Perfect. Thank you so much. This was a great interview you gave us so much to think about as myself as a practicing clinician. So this was great. Thank you so much. 43:31 Pleasure, absolute pleasure. And thank you very much for having me, Karen. Yeah. And 43:35 everyone. Thanks so much for tuning in. Have a great, great couple of days, stay healthy, wealthy and smart. And also if you hope to see you in Denmark, so there's still time we've still got a couple of weeks before the end of August. So if you haven't already, sign up because it's going to be great. So thanks, Seth, and thanks everyone for listening and stay healthy, wealthy and smart.