Achilles Tendons (Part 2) with Karin Silbernagel

Speaker 00s - 12.84s

Finally. Okay. We're back for round two with Karin. So you were recently at the Professional Football Athletic Trainers Society ORG. I googled that acronym. Yeah, tell me how that went.

Speaker 113.84s - 36.04s

No, that was actually, it was a lot of fun. I think they did a really good organization. And it's always fun for me to be out when it comes to people that are out in the field and the clinicians and hear in the questions and things too. So I really, really enjoyed it. We had a really good session on one day and then it was a panel on the next day. So it was fun. What are their concerns?

Speaker 037.42s - 42.46s

Well, I think the concerns and I think what this was really talking about tendon health, right?

Speaker 142.7s - 82.88s

It's tendon injuries, as we've all seen in the football season, right? We've been a lot of increase in Achilles tendon ruptures. I think there was like 20, 25 maybe this past season and Achilles tendon ruptures and understanding why is that happening. And then tendon injuries or painful tendon tendon tennopathies are always something that people are battling with. In season, it's hard, right? How much do you have people not continue playing? When is it? So that balance is really, really hard,and especially when you're getting to playoff games and things too. And then there's a lot of questions on how do we actually prevent Achilles Tender rupture and how do we really get to it?

Speaker 084.44s - 95.54s

Yeah, that's a fun question that Achilles tendon rupture and how do we really get to it? Yeah, that's a fun question, the Achilles rupture prevention. Where is your head at for that? How do we prevent Achilles tendon ruptures?

Speaker 196.24s - 178.56s

Well, I think that, again, maybe we talked about this the last time too, but I think we need to focus on tendon health, not on tendon injury, right? So thinking like how do we keep the Achilles' standard healthy? Because some of these rupture might be just things happens, right? Any injury, it's an accident and we might not be able to prevent it. But the healthier tendons that we have, the less likely we probably are to having some major ruptures. And one of the thing that really hit me when we were there for the,for the conference, too, was the first day was all the athletic trainers. And I'm talking about, like, how do you keep it? And I think really strengthening the calf is important. And you ask everybody in the room, 200 people, how many goes into the gym and actually do calf exercises? Or do you only do quad? And I think we were four of us. I think it was me and Jared and somebody else. I mean, the four of us raising the hand that we actually do calf strengthening when we go into the gym. And then the next day when the strength and conditioning coaches was theretoo, I think there was about the same number of people. So I think one thing thinking about the tendon attaches to the calf muscle. So strengthening the calf muscle, loading the tendon, just putting that into some kind of exercise, I think is important. And I made them in the workshop do 30 heel rises on the right and 30 heel rises on the left.And people were having a hard time doing that. Yeah.

Speaker 0179.36s - 186.6s

Yeah. Why do you think that is that the calf, just the simple calf raises or calf strengthening has been so neglected? Well, I that is that the calf, just the simple calf raises or calf strengthening, has been so neglected?

Speaker 1188.24s - 232.06s

Well, I think partly that the calf is fairly sturdy muscle, right? So rarely do you have, wow, just a ton of weakness. So I think that's part of one thing. And then I think it's just not something that we've done, right? I mean, sometimes people go in and strengthening they want to do things that can see in the mirror or things that people are telling them to do,right? People didn't do a lot of hamstring strengthening until we really started talking about Nordic hamstring exercises and the hamstring strain and things too. So I think it's, it's just one of those things people are walking around with. I mean runners, you figure runners should really do calf strength and don't care about the calf, but they go in and do the other muscles. So I think it's just history, and I think maybe we can change that.Yeah.

Speaker 0233.36s - 253.16s

Okay, so last show, I said I, we only covered half of my questions, so we're going to, let's get to the other half. So I think in previous shows, you've talked about people coming back from rupture, and the Achilles tendon will get longer, more compliant. Why does that happen?

Speaker 1255.42s - 336.74s

I mean, I think that's an, well, an interesting question. I might not be able to answer. But what happens is when you have, so basically the studies have shown to you that it's not like you have a lot of different collagen fibers that attach to different levels. Probably the collagen fibers go from end to end more in the tendons. So if you have tendonopathy and changes, maybe it's not the rupture or the collagen. It's more like between the fibers and changes. But when you have a rupture, the fibers are completely ruptures. So you get like a mop-band in between. And when you have the mop-band, and especially Achilles tendon, when you have twisting, too,it's not like they, after they rupture, find their body on the other side and start healing together. So that's not how the tendon can heal, like from one fiber to the other. So you heal as a more of a callus, just like you do with bone, right? You start producing kind of around thatfracture side of the rupture to pull it all together. And the body is not able to heal it, to make the tendon go back into its perfect nicely shape. So instead we heal with a lot more tissue so we get this really big callus to heal it. But if the tendons were normally twisted and now they're untwisted and then you have more of this around it, this tendon is going to be longer, right? So it's just going to have some kind of elongation. And this part of the elongation seems to be part of the problem.

Speaker 0338s - 345.3s

And that would, even if someone does non-surgical, the mop-ins are not going to find each other. It's going to still be a callus.

Speaker 1346.44s - 401.14s

Yeah. So the interesting thing is that, you know, everybody, when you see a rupture, you can see the vibration all the way up in the calf. So everybody assumed that this tendon flew up and ended up in the back of the knee. But it's just the wave of the forces. It's not that it's rupturing. So the tendon ends are fairly close to each other, right? Even though they're not right there, they're fairly close so they can start healing. So regardless of if you're surgery or non-surgery, you can actually form this callus and heal verywell. Some discussion is like when you do surgery, a lot of times you cut the parotinin. So that might be negative, but now you put the tendon ends together versus if you have do non-surgical, the parotinin stays probably intact and maybe that's beneficial. So it might be that certain things are benefit for going non-surgical and some for surgical. But the interesting thing is that the outcomes are not very different if you do surgery or non-surgery.

Speaker 0402.52s - 428.98s

So, yeah, the parotinin will usually stay intact if you don't, if you don't get the surgery. Okay, I didn't know that. Yeah. And then when it comes to Patelor tendon, that's not like, I've kind of had that thing where like, okay, Achilles tendon ruptures, they repair it and they want to repair it stiffer because it's going to get a little bit longer with that whole regeneration process.Is that not happening with Patela? Patela and quad?

Speaker 1429.6s - 498.3s

No, it's actually happening too. And we see less patella tendon ruptures. I see more like in older people and thinking Patelotendor ruptures. We see it in athletes too, but a lot of people fall in the stairsand have like the forced flexion, right? And then you can get a rupture that either pateteleotendent or quad tendon ruptures. And what we see with peteleotendentin, too, that some people after the patella tendon rupture have difficulty with full extension and they have an extension lag. And sometimes that relates to the tendon elongation happening there as well. So you can actually see, and we've started to measure that.So that's why it's really, really important. I think they're better, I think you have a little bit of an easier from the quadriceps, which is a longer muscle, right, than the gastroc and the part of the solace. So you might be able to shorten the muscles more. So then you can maybe compensate for a little bit more of the elongation. But if that tendon, it heals too long too. That's why people have real difficulty with the lastfive to ten degrees of extension. But if you have hyper extension before, you might have lost five degrees, but you might still be extended. But it's actually a big problem.

Speaker 0499.22s - 514.6s

Yeah. And once if that's, I mean, they must have back in the day repaired people more frequently not stiff enough and they just got had a longer tendon and they probably are on top of that now. But what, what, there's nothing you can do outside of getting another surgery, right?

Speaker 1516.02s - 574.5s

Well, I mean, there are, I think from some of the studies now too, I think we've had a shift, right? Because we started talking more about the tendon. The doctors were worried about from the Achilles tendon and things due to tighten it too much. And then we started to show that this elongation is happening. It's happening regardless. And there might be an issue.So I think there probably is a shift. If we do the same studies now, we might get slightly different results, right? Because if people starting to tightening up more and the surgeons that I speak to, they're less worried about tightening up because they know it's going to elongate. So that will be a benefit. And it is related to how much you have tightened upbecause you're going to get elongation, right? So if you start in tightening, you might end up a little bit better. The biggest problem, though, is that there is so much variability, even if you have the same surgeon, you have people with bilateral injuries and things,and one elongates more than the other. So there are probably things that is hard to control to kind of see these differences. So now I forgot what you're asked.

Speaker 0574.74s - 616.68s

Yeah. No, no, that's good. The, I wanted, I've been thinking what you said on the, the differences with tendonopathy and tendor rupture. Because it was a Michael, Michael Kerr PERSON was on a, someone's show, and he was talking with tendonopathy and tendin rupture because it was a Michael Michael Care was on a someone's show and he was talking about tendonopathy being kind of more fluid around the collagen fibros instead of actually because that whole thing that they're they're continuousthrough the whole tendon in the collagen fibros and he was thinking that the tendonopathy was more of a fluid accumulation around there like proteoglycans and then you can actually just kind of squeeze it out and get good results with tendonopathy was more of a fluid accumulation around there, like proteoglycans, and then you can actually just kind of squeeze it out and get good results. With tendinopathy, so you're not thinking that you're getting a lot of, or any collagen fibral breakage?

Speaker 1618.28s - 674s

No, I mean, that's like the big discussion, like what are partial ruptures or nonpartial ruptures and things too? I mean, I've seen people with tendonopathies that have like, looks like, well, the holes in the tendon, and you're like, oh, wow, this is a rupture. But I really don't think it is. And some of the doctors have talked to, too, can you drain what's in there? And I think about it more also, exactly what Michael Care is saying, right? You probably have swelling. You might have tears between the collagen fibers, but it probably not as much discontinuation, right? You probably have swelling. You might have tears between the collagen fibers, but it probablynot as much discontinuation, right? You have this kind of changes, increased fluid, disorganization that looks very differently. So that's kind of how we're thinking tenenopathy versus rupture. It just tears. But, you know, partial ruptors, I don't believe in, but then I've seen that they probably do exist too, right? So there might be something in between and we probably can't account for everything. But that's kind of what makes a little bit of the difference between the two.Yeah.

Speaker 0675.28s - 690.5s

So this whole, I don't know how recently this came out, but the interpricicular matrix, hazel screen, a lot of that work. What do you think's happening there with tendopter with Tendentopter PRODUCT? Yeah, good question.

Speaker 1690.68s - 787.48s

So I do think there is, you know, from the basis, from from Hazel Screen, Jess Nettaker PERSON, Michael Care, I mean, all of them done really, really good research and what we're looking at. And probably what it is is in talking about from the, you know, the low bearing tendons and things, so you probably do have a core of tendon kind of structure that is less things happening. And then you probably have some other pieces of the tendon or more maybe around or whatever that is more having a higher turnover.Right. So that probably makes kind of sense. And what happens probably with tendonopathies is when you're loading and your turnover recovery gets out of balance, right? So you have more breakage or more degradation versus you have positive turnover. You get into this negative balance. And this negative balance is probably related to overuse for tendonopathy, right?But overuse could be the same load, but now you were sick for three weeks and your system can't keep up, right? Or we see metabolic factors, prediabetes, cholesterol, like if you have an environment that may not to be positive, maybe the same load all of a sudden becomes an overuse. So we see changes in menopause, like, you know, your hormonal changes. So I think it is some kind of imbalance and then, you know, some call it metabolic tipping point or whatever where thetendon is not staying healthy. And I think it's related to overload, but I think or overuse, but you need to think about it that, right, if you were sick for two weeks and you went back to did exactly the same program that you did before, now your body just can't respond as well to it.

Speaker 0787.58s - 789.22s

So I think that's what we're looking at.

Speaker 1789.28s - 826.26s

When you're looking at ruptures, I do believe, and this is probably more a belief than anything, healthy tendons don't ruptures. Healthy tendons are really strong and really have a big safety margin around them, right? But on the other hand, tendons that rupture really have had symptoms. So maybe they are in this kind of turnover face a bit earlier, but they haven't developed symptoms yet.Or maybe if they developed symptoms, they might be a little more productive, right? So I do think it's probably part of a little bit, but it could be somewhat different stages of when you're at, when you actually have the injury.

Speaker 0828.24s - 859.64s

So, yeah, that whole thing, healthy tendons don't rupture. My head immediately goes to, and probably you get this with birth pro athletes worth millions of dollars where they're frequently checking the health of the tendon with imaging. But what do you, how do you think practically people could, like someone who doesn't have the money for imaging every six weeks or so, like how do you know?There's no way you know if your tendon's healthy or not healthy because often you won't have symptoms. You like what's, you know what I'm saying? I know exactly.

Speaker 1859.64s - 864.54s

Yeah. Yeah. So do you feel like this is something in the future where it's like for Achilles

Speaker 0864.54s - 870.5s

prevention, we're actually going to be imaging people's tendons more frequent? Or do you not think that's the thing?

Speaker 1871.02s - 965.14s

Yeah, I think, well, you know, it's, I think there's two really big problems that we're having, right? I think imaging is really nice because it shows structure. Just like even in the muscle or measuring muscle size. People are and professional sports. Some of them are very worried about imaging tendons because they don't want, and the players don't want us to tell if the tendon is injured or not, and I'm trying to push it.No, we're just making sure how healthy your tendon is, like turning it around. So there is a very, very fear of doing imaging that we're going to classify things that are not there, right? So that's one piece of the puzzle too for healthy. But I think it's like with everything, right, you're going to try to maintain that you're healthy. I mean, how do you know, you don't go and do blood testsevery day, right, to make sure that your cholesterol is right or your blood sugar is right. Or, you know, you try to do the right things and stay healthy, and then you can do checks and things too. I mean, ruptures, very, very few people ruptures, right? I mean, Achilles tendon rupture is not a common injury, right? It's just isn't. Tendinopathies are, and then we have early signs and things too. So can you protect yourself from all injuries? No, injury prevention is really, really hard, right?Every kind of injury prevention program is like, I don't think you can prevent injuries, but you can keep yourself as healthy as possible. So I guess what I'm getting at, if you do calf races, if you do strengthening, try to load your tendon,listen to your body when your performance goes down. Maybe I need some recovery. And thinking about your overall health probably helps your tendon as well. formans ORG goes down. Maybe I need some recovery. And thinking about your overall health probably

Speaker 0965.14s - 1049.14s

helps your tendon as well. One of my first shows was with Peter Malieris PERSON. And I kind of had a similar question. And he was, he was just like common sense prevails. And I was like, that's pretty, that's pretty much it. I use that pretty frequently. I was, so I was talking to, I was talking to Jared Amphick a few days ago. And there was, I mean, this is getting to our later question on the donut versus the whole thing about this area of pathology and kind of how the structural abnormalities get become common once you reach like 40 years old or older. Like the tendon health, the tendon structure can look very poor.And he was kind of painting in my head kind of two pictures where it was like for that group of people who's much older, 40, 50, 60, whatever, they have the structural abnormalities. But they're probably going about doing laundry and dishes and having a pretty low demand of their tendon. But then you have the athlete, like the NFL or NBA ORG athlete who if they have to run, what a sprint as fast as they can, jump as high as they need to, like, I wouldn't want a tendon that has all that bad structure.I think that would be a tendon that's very likely to rupture. Do you kind of think the same way of like, if you have a person that's really stressing the Achilles tendon, you would probably want that as healthy as possible versus if you're 60 and you're just going for walks every day, kind of like, who really cares, unless you have pain? Is that something you kind of think of

Speaker 11049.14s - 1168.4s

there as like kind of two different camps? We see it, right? So we, yes, I do agree. I mean, I think that if you are, anytime you're pushing yourself to the limit, your body has to tolerate pushing yourself to the limit, right? And that's what we're talking about. There is a safety margin built into how strong a tendon is, right? So it's the same thing if you're tying up a boat and there's not going to be a storm, you know, your ropes, you don't check your ropes as much. It doesn't really matter, right? They're going to be fine.But if a storm is coming, you might get some other ropes or make sure that you actually, there's no wear and tear in your ropes, right? So that's kind of the analogy that I would keep for that. But we do see in our subgroups that we look with Achilles tendonopathies and things too that we look at the various, we talked about this before, various parts of the domain, structure is one, function is one, symptoms is one, fear of movement is another, and personal factors. And all of these are independent factor that relates to the Achilles tendon health, but it doesn't mean thatone person with really horrible looking tendon might not have pain versus another person might have pain, but doesn't look as horrible, right? So they're kind of independent factors. And we do see this group of tends to be older, overweight, obese males. They have this horrible looking structure. And the function might be lower too, but they actually don't have that much pain. So I don't expect for their rehab that that tendon is not going to look like what it did when they were 20 years old.We can see improvement in structure and changes to. My expectation wouldn't be to go back to look at as when it was new, right? It's the same thing when we're talking about knee cartilage or all these other things too, right? We can get people back to 100%, even though their cartilage are changes and things. It's not a direct relationship, but if you have really horrible looking tendons, you're probably otherreasons that that tendon might not tolerate as much, right?

Speaker 01170.16s - 1218.44s

Yeah, every once in a while we'll find Achilles PRODUCT. You had a presentation. You've had a few Achilles rupture videos. It was mostly athletes, though, but I've been finding them recently with the older males. One was at a trampoline park running up that that ramp and he popped his Achilles on the ramp and one guy was just skipping popped his Achilles and that makes me think of that that has to beone of those structure groups where they're doing something that's like pretty harmless I guess the running up the ramp was this guy was just like skipping and very harmless maneuver and it's like the Achilles just pops and I'm thinking like that has to be someone who wasn't didn't have much function to begin with like their function was pretty low to begin with. Probably had a really bad tendon. They go and do something they haven't done in five years and pop the Achilles goes. So, yeah, the solution for them is maybe just don't go do something you're really unaccustomed to like that.

Speaker 11218.44s - 1224.96s

Or work on your calf when you go to the gym, right? Right? Like with anything, just make sure that

Speaker 01224.96s - 1227.28s

you maintain health in that kind of sense.

Speaker 11227.34s - 1228.6s

I think that's an easy answer.

Speaker 01228.98s - 1271.14s

Yeah. Yeah. Okay, so going on to tendent strain. So this thing, tendent strain, I've been spending maybe the last two years really trying to understand and I still barely understand it. But just elongating, getting tendon elongation throughtraining. Yeah, so there's this idea that you need to get a high, like a high load, high pull from the muscle. But then Greg Lehman had, I think he had a series of like two articles talking about stretching because you could just change the joint angle and then you should in theory get the same type of strain in your tendon. Yeah, where do you stand with that? Because, you know, the strain comes from the muscle pull, but also the joint position

Speaker 11271.14s - 1316.88s

that I'm like, could you just get into an extreme joint position? And would you get a similar effect on the tendon or not? So the problem with purely doing stretching is where you're limited by your joint, not by your tendon or your muscle. So it's not just, it's not just, you need, in order to pull apart a tendon, it's not just changing the ankle.It's a lot of force that you need to pull through it, right? So if you're stretching, you can measure how much force that will be, like in the dorsiflection. You can actually measure the force on the foot. That amount of force to stretching is going to be a lot less than the amount of force you're doing if you're putting 100 pounds on your back and try to hold that position, right? Do you know what

Speaker 01316.88s - 1324.86s

I'm getting at? So if you if you didn't have the limitation of the ankle joint and you could

Speaker 11324.86s - 1350.42s

pull that tendon passively, that's what we do when we test strength, when we take them out of rats and things, right? We don't have a muscle contraction. We pull it and we'll see when it ruptures how much strain we can get. But in order to get that in a human, you can't just pull one end to the other to get that amount of strain.So the muscle has to put a lot more contraction to it to actually get that amount of strain in it. Does that make sense?

Speaker 01350.52s - 1385.4s

So it's not just a stretching. It's the amount of load they're going to get the tendon to strain because the tendon needs a lot of load in order to get a few percentages of strain. Yeah. And then even getting into a super, like the most extreme joint position you could and then you try to pull the muscle, you wouldn't necessarily want to do that either because the muscle can't work that well. You'd want to find like the optimal position. Right. Yeah. Yeah. And that I think is that is such a key point too when you're working with people with Achilles tendon ruptures and elongation. I see a lot of people want to, they have difficulty going up into the

Speaker 11385.4s - 1418.44s

end range of planoflection. So then people want them to train in the end range of planoflection. But if your muscle is in an active insufficient position, you know, your strength and conditioning. You want the muscle to be able to generate a lot of force in order to get stronger and have some hypertrophy, right? So if you work in a range when you can only produce a little force, you're never going to get stronger. You're better at, you're better strengthening in the mid range when you can produce a lot of forcebecause then you're going to get stronger in the end ranges too, right? So that's kind of the other piece of the puzzle.

Speaker 01420.3s - 1459.46s

So when we go to, you're probably the case of rupture or someone that's had like a very chronic tendon pain is the muscle wasting, muscle strength, yeah, muscle atrophy. They just get weaker. It makes me think they wouldn't have the capacity to get enough tendon strain. So because the muscle is so weak. So would you spend time in those groups of people doing like very, I would think, for me, I would think very high rep or even like blood flow restriction trainingto attempt to restore the muscle size, which you're probably not even having really any effect on the tendon because the loads would be so light, I would think, at least. Is that kind of what you would

Speaker 11459.46s - 1493.68s

think? Well, that's kind of what I thought with BFR, right? Maybe you do it to see it changes in the muscle. And then when you have muscle active, they would pull on the tendon and those kind of things too. But BFR seems to have some effect on the tendon or much earlier than I thought as well. Right. So what we know is true is not true ever, right? But I think what the interesting thing, what we started doing too is really looking at.So you've heard about the Spanish squat and Angel Basas PERSON. They used to do the in the Spanish NORP squat electrical stimulation for Patelot tendonopathy. And his, did I talk about this last time.

Speaker 01493.68s - 1499.02s

You just did briefly. And like an hour ago, I just pulled up that study. And I was, I was going to ask that.

Speaker 11499.06s - 1609.34s

Yeah. So what they did is like doing the squat and then adding electrical stimulation. And you can actually sit in that squat a bit longer. And we see that you can get more strain on the tendon. It's, you know, we measure the distance between but attached on the tibia and the, and the patella.We can see the difference in the length. You can get more strain on the tendon when we add an electrical stimulation to an exercise that you thought maybe was really difficult too, right? So we are really interesting and we're starting studies here now looking at the use of electrical stimulation because if you're measuring the amount of force, even for planar flexion of the ankle, right? So if you're lying down and you're doing a planar flexion and you're looking at the force output, probably not all of that force output is from the gas drug or the solace. You have, you might push a little bit from the hip, you might haveflexor halos as long as you have all these other things that you can kind of generate more force, right? So the body is designed to compensate to achieve a task, but sometimes when we compensate, we might not get the same load in the, in the tendons. So we are proposing that, you know, how you design it and making sure maybe electrical stimulation is the way for us to actually pinpoint the muscle to get enough force to that tendon. And that will be electrical stimulation along with active or it could be passive, right,to looking at those things. Because I think that is part of the problem. We assume and we tend to give our expectations a lot of various exercises, right, to we're going to do functional and this and that. And maybe they can do it, but maybe they don't lose, you know, maybe they don't use the muscle we think they're using to the high levelor we think that they should be, right? So that's why simple strengthening, maybe seeded calf races or you're standing. It's much better than trying to get all fancy or maybe electrical stimulation on it to maybe short to pinpoint it. That was a long answer to that.

Speaker 01609.34s - 1621.86s

Yeah. Yeah. So I briefly looked at that study where they did the Spanish NORP squat and then they put the electrode, the e-sim on. And that one person had like a seven times increased tendon strain.

Speaker 11622.22s - 1630.56s

So it was the tendon strain. It was increased within the spanish squat. So they, they just looked at the location of Patella and Tibia and they saw that it

Speaker 01630.56s - 1636.74s

was just more. Basically, basically what we did was you go down into the squat. You can do an

Speaker 11636.74s - 1672.62s

extended field of view measuring. So you can get a picture that goes from the attachment to the tibia to the patella, the tip of the patella, and measure the length. And then you add the electrostimulation, you do it again. You can see what the differences are within that, right? So it's just illustrate that we're able to get more pulled onto the tendon by adding a little bit more. Because it could be that people can sit in one position or they can compensate.They have other things. Maybe they lean forward a little bit more. I mean, you know you're training people, right? The body's meant to compensate, but that could be a problem when we try to pinpoint certain things.Yeah.

Speaker 01673.26s - 1680.04s

Yeah. It's like having a petal or tendon person do a squat and they do it all with their hips. Exactly, right?

Speaker 11680.16s - 1692.12s

I mean, that's what it is. So in order to really get that tendon loaded, you can probably give them to do 300, right? And they might load less than somebody that did 10 because they were able to load it more.

Speaker 01693.24s - 1699.04s

Yeah, so that's what you're working on now, is how you can get more, and you're doing it with Achilles, how to get more Achilles strain with that.

Speaker 11699.1s - 1699.34s

Yeah.

Speaker 01699.54s - 1702.32s

So right now what we're looking at, which I think is fascinating,

Speaker 11702.5s - 1738.12s

we're trying to look at stimulated with electrical stimulation, and we do the tensiometry, like the tendon tapping and see wave speed through the tendon. And we try to do that comparing with active voluntary contraction or with electrical stimulation. And it seems like for just the way we're measuring it, we might be able to get the same load in the tendon at less forces when we do electrical stimulation than when people are pushing, they're probably pushing with so many other muscles, right? So the force output looks a lot higher, but the tendon strain is not as high as you think it is.

Speaker 01738.44s - 1740.5s

Yeah, yeah. It's cool, right?

Speaker 11740.84s - 1745.72s

Yeah, it is. I've recently, like, been thinking on tendon strain because I,

Speaker 01745.72s - 1785.9s

it's kind of been repeated so many times with patellar tendon that, like, you can do heavy isometrics and people will tolerate them well. But I've had a number of people that I give, like, 30 to 45 second long, like, extension isometrics, and it just blows up their tendon, and they're much worse. And I've pretty much confirmed that it is a tendon because you could think it's like patelefemeral or some different off the diagnosis. But I'm like, no, I'm pretty sure that is a pateller tendon.And it just makes me think is, are they at a point where that's too much strain? They have a very unhealthy tendon. So is that kind of what you think, too, is like if you have someone with a very unhealthy Achilles or Pateller, you might not want to get a lot of strain in that tendon, right?

Speaker 11786.64s - 1876.38s

Well, it might not be, it might be that you want to get a lot of strain, but depending on how long period of time, right? You know, it's both the, it's both the peak force, the time under tension, the rate of loading. I mean, all of those three variables we can change. The rate of load might be a problem if you want, you know, because high rate of loads probably is when you rupture, right? But you might want to be able to do lower peak load and have a longer time under tension,you know, or you might want to say I want to have a high peak, but I'm going to do a lower time on attention, right? So you can manipulate both of those variables to not overload it or overuse it to do too much too, right? So I think that's absolutely what you're looking at. And I, the other part, I think, too, when you need to think about is, I think for both patella tendon and the Achilles tendon, thinking about what the position is, do you have compression in the position they're sitting inor is it purely tension, right, strainrain in the tendon, too. Because sometimes I worry about people with patella tendonopathy, you're talking about in the center that generally the injury sits right at the patella pole, the distal tip of the patella. And maybe there's compression in that area more so than just strain, depending on which position they are. So we try a lot, too, to try to even for the Achilles, right?Do you want to avoid dorsiflection, find a position when you have less of a compression in the area and maybe then work isometric in that area, work concentric, eccentric, eccentric, but not within that position, right?

Speaker 01876.88s - 1905.9s

Yeah. Yep. It throws another wrench in to thinking you'd have it solved of why they had a blow up of, a blowup of symptoms. So before we got on, you were talking, I think this will relate the donut versus whole thing. And you were saying the differences with Piteller and Achilles because the Pateller PERSON, right at that inferior hole, you'll have that hole, that tendon hole, the degeneration, wherever it is. But the Achilles is a bit different.Could you kind of explain that? Yeah. So, I mean, I think that the structure of what the tendon hole, the degeneration, wherever it is. But the Achilles is a bit different. Could you kind of explain that? Yeah.

Speaker 11906.02s - 2037.16s

So, I mean, I think that the structure of what the tendon looks like, you need to think about, right? The Patelotendant is a very flat, broad, and then it's thicker at the center, right? So that's the kind of the tendon. And you can divide it. We're looking at it from a medial, lateral, and central portion. We kind of divide it up when we're looking at it.And we actually see different mechanical properties in the different positions, too. And maybe they are loaded differently. So instead of the Achilles tendon, you have three subtendens, but they are twisted in one. Here, it might be thinking about it more of a broader, broader as a sheet. And then the teletendent tends to have it, the changes of tend to be right at the center in kind of the middle of the tendon too, right, right at the distal pole. So that's kind of whereyou see the tendinosis kind of occurring. And then the people are talking about it, oh yeah, that's like the hole in the donut and then you see the healthy tendon around. The problem with that is that it's also right where you have the compression. And that might be more where you have the fibers going directly from the patella to the tibia versus there might be different kinds of strains too. Right. So I think that is how it looks at that too.But when you're looking at the Achilles tendon, there is no, there is no donut. There is no hole, right? Because now you have three tendons that are twisted. And here we're more interested in maybe it's occurring more in the shift between the different tendons. Are there parts of the medial, lateral gastroacosolias that are more irritated than other?And one of my colleagues here was just starting looking at it. And she looked at one kind of with high imaging, the MRI imaging and things too. And sometimes for some of them it seems like maybe it's just more of the solar or more of the medial gastrook or more of the lateral gas rock, depending on positions, right? And UTC is starting to look at that too. But then it's more of one tendon, but that's, it's not one tendon in the center where the problem is, right? So then you have more of twisting. So when you're looking at the different types of tendons, they don't all look like they have a hole and in a donut, but that's what base from patelot tendon and then kind of got infer to other things too.

Speaker 02038.68s - 2057.14s

Do you think that, like if you have an overuse of one of those subtendens, do you think it, is there any commonalities with someone's foot posture? They're like more of a pronated, suponated, the position of the cacanias. Is there any correlations of overusing one of the specific subtendens or is it just all individual?

Speaker 12058.22s - 2168.04s

Well, I mean, and that's like the Holy Grail, right? So I, I, we looked at static posture, navicular drop, navicular drift in all our individuals to see if there seems to be a relationship comparing the injured side, the non-injured side or to normalize data. And basically what we see, we can't find anything because part of the problem is some people have more supernated feet and some people have more pronated feet. So when you put them all together, on average, you're not going to see anything, right? And then if you start thinking about if people have different twisting and how they are twisted,now they talk about three different types of twisting, right? So if you put three different types of twisting in with a variety of foot postures, on average, you're probably not going to find anything, right? So that's, I think, the problem with the research. Mechanistically, if there are ways of people have different twisting and different loading and those things, some people that I do see seems to have a straight edge of the Achilles tendon laterally, but more swollen immediately, for that person,I'm wondering, oh, are they more of a pronate or are they loading more on the medial side, right? But then you can start thinking about, well, which subtendent is that? So is it more from the lateral medial side? Maybe it's more the lateral gastroar because they're pulling it up more versus that the foot posture is dropping it. So there's nothing there to say that it's,if you have somebody the pronates, they're going to develop Achilles and apathy. Absolutely not, right? Probably extremes in posture maybe, right, or if they can't function. But then you, you can see people with horrible looking feet, no problem whatsoever. They can run forever, right? So I think we've got to be careful, but I'm really interested in the mechanism that possibly could explain it.

Speaker 02168.24s - 2185.56s

That was a lot of work for a non-answer, I guess, but. And then when someone ruptures, this whole subtent, the three tendons and the twist, they rupture, they get it repaired. There's no more twists, right? There's just, it's just, so then they just got to work with this, this callus.

Speaker 12186.28s - 2252.46s

Yeah, they're going to work with a callus too. But, but I think the, the interesting thing is that it works really, really well. I mean, in general, in general, not a lot of people have ruptures. And once they recover, they actually do really well. If they, long as this tendon is not way too long, but then even with longer tendons, people tend to adapt pretty well. I mean, there's one point where the muscle can start to remodel, probably changing the fiber lengths and things too.So I think the body is quite amazing in that sense. I just kind of want to put that out there too. And we've looked at tendons up to six, seven years, and you still kind of see this callous. And the tendon kind of gets really, really big and then it gets a little bit slower, but it never goes back to lookinglike the other side, but people function well, right? So there is probably something to be said for, you know, more is better if you don't have quite as nice of alignment, right, versus the other one might be more efficient, but you can do well despite that. But, you know, everybody that you see with a rupture, you can tend to see the medial gastrook looks a lot smaller. That's what people are concerned about.

Speaker 02254.66s - 2265.6s

Yeah, going, sorry to go back to the callous thing is you have those fibroles going end-to-end in a healthy tendon and then you rupture it, what are those fibroles then attached to?

Speaker 12267.64s - 2321.08s

So, well, we have to go and cut it up. No, but think about anything that you're doing, right? I think about it as you're kind of putting this whole structure around it, right? The body is trying to regenerate, trying to hold together, glue together. Is there ever a, you know, a collagen fiber that can kind of grow together or not? Or do you have more of like, you know, the parts between the fibers?Is that what's getting stronger, right? Or you're having more of those things. Are there more glue? Can the body regenerate? I mean, it tends to just kind of put it all together and then it starts to regenerate. It's kind of like when you have a scar, right? Some pieces of a scar you can barely notice and some pieces of a scar, you can kind of see where the changes and things are. So I think it depends on when people are healing, how people are healing as well, too.

Speaker 02321.88s - 2352.2s

So you said that the non-surgical surgical Achilles PRODUCT kind of equal results afterwards. With athletes, have you seen athletes do, like athletes who need to be explosive with the Achilles, have you seen them go non-surgical and be good? Because for my take, I've heard probably many different anticoats, but it seems that the non-surgical don be good? Because for my take, I've heard probably many different anecdotes, but it seems that the non-surgical don't really have that explosivenessor that pop in their Achilles PRODUCT afterwards.

Speaker 12353.14s - 2486.72s

I mean, the data that we have is that some people non-surgical are better than people that are surgical, right? So when we're looking at the jump and those kind of things, too. There are two problems to the questionsthat why it's hard to answer is that when you have an elite athlete, we are very worried about going non-surgical because everybody is really worried about not doing anything, right? So it's one of those things. Probably elite athletes will do very well non-surgically because they are, they have, they're generally very healthy, you know, I mean, they can take time and exercise whenthey need to, you know what I mean? So they might do very well, but I think in general, there are very few times where we, as people that take care of them, dare to say go non-surgical, right? Because if they do surgical, they don't do well, then it is what it is, right? But if you go non-surgical and you don't do well, then it's because you didn't do surgery, right? So it's that kind of pattern. But I have had patients who are like the level below, right, that are, and especially within Sweden GPE and things, too,that I was like, yeah, I don't have time because they're still working and things. I'm happy to go non-surgical. And some of them do really well. You know, it's the same variability. I think the biggest issue we have nowadays, too, we don't see any differences in the newer studies between surgical and non-surgical, but we just discussed yesterday. Some of the results nowadays are worse than it was with the results that we did in Sweden GPE when we did our studies in general. So why are people doing worse? And one of the things that we were talking about inall our studies, at six months, we tested everybody, regardless of age or if you athlete, non-athlete, and we tested them by making them counter movement jump, we made them do hopping, we made them jump off of a box and then jump again, and we strengthen them and things too. And I think that testing actually helped people get better at one year when you compare the data at one year, right? Because people came in as like, you're going to make me jump off of this box. I'm like, yeah, you can do it. So people walked out and feeling like,wow, I can really do this. And I think that kind of testing actually helped people push themselves further and maybe doing better. But that's one of my current biases. Oh, yeah. Yeah. Is it kind of

Speaker 02486.72s - 2496.06s

a thing with countries, too? I don't know where I heard this, but in Canada GPE, are they more likely to do non-operative? And in the States GPE, it seems like they just wanted to do operation.

Speaker 12496.98s - 2583.44s

Well, yeah. So for example, we had in Sweden GPE when I was there, they started doing non-surgical, and then we did one study showing that maybe surgery had less re-ruptures. And then people got more surgery. And there was another study showing that non-surgical wasn't. So now in Sweden, I think it's 50-50. Denmark GPE went from doing surgery to barely doing no surgery, a lot less surgical in Denmark at this point to. Norway GPE just finished a study with comparing like no differences and there was a study in Canada GPE and now I can't remember his name. They did a really good study too around the timewhen we did studies to showing there was no difference between surgical and non-surgical. So within this system, when you have a really big study, then that Canada GPE went to a lot more non-surgical as well versus the US GPE has been much harder to kind of make that change, probably because of, you know, how the medical system is set up, how people are trained. There was nobody here that did that study, right? So it's easier to influence within the country where you're at or if somebody that is wellknown and things too. But I would say the, I've been back in the US now for 14 years, something like that. And I would say that there's been definite shift in the American NORP surgeons too. I think more and more are, we're taking very welcome to do people non-surgical. And we do a lot more non-surgical here because I can do imaging and we can kind of control it. But again, non-athletes tend to be.

Speaker 02584.06s - 2615.68s

Yeah. That, I don't know who I, one of my friends maybe, it reminds me of one of my friends, he was in the NFL ORG for a while. And it was like when people will get tendonopathy. They didn't really know what to do. I don't know, this is many years ago. And it's like, you got to look like you're doing something. So they give them PRP, PRP injections, like pretty quickly. And it's like, it makes a whole lot of sense because you would hate to just sit there and do nothing. And then the coaching staffor people above them are like, well, what are we paying you to do? Exactly. I mean, and I think

Speaker 12615.68s - 2621.58s

as humans, we rather do things than not do things. And I think that gets us in the way sometimes

Speaker 02621.58s - 2625.94s

too. Like, you know, probably maybe Jared PERSON said that too. Like a lot of

Speaker 12625.94s - 2655.16s

times people train the tendonopathy's too much or try to do too much. I mean, letting to train and recover, being allowed to recover, but that any time you work with an elite athletes, getting them to eat and sleep and not run for the runners and things too, that might be the best. It's really hard to focus on that right instead of doing and then then people want to do PRP we're going to injection we're going to do cross feature you want to do so many things instead of letting body the body actually work the body is

Speaker 02655.16s - 2683.34s

working even if you don't see it right yeah and it's probably that whole slow the kind of slow healing process that you don't you know you don't want to wait for that um so this whole thing it was it's kind of been repeated that the the people that have tendon pain don't often go on to rupture um is that still accurate or has that kind of been challenged because it seemed like i don't know what it was it was like yeah go ahead yeah no it actually it is very

Speaker 12683.34s - 2772.5s

accurate in the sense that because we have a lot more people with tendinopathy is when we have ruptures. And the majority of people, the rupture have not had pain right before the rupture. Somebody was talking to me, well, but I saw somebody the rupture had pain. Yeah, but if they've had pain, it's not leading up to it. It's not like I'm going more and more pain and then I rupture. Some people had pain like a year ago and then they ruptured, probably had no pain beforehand,right? So there is definitely that balance and it's definitely true. The only group that is not true. And we see actually an increase in Achilles and ruptures in young collegiate female gymnasts. And the majority of them have had symptoms before, right? So now you have, in general,it's mostly men, no symptoms. And now you have this group of young female with pain that are rupturing, which is kind of sad, right? But probably it relates to the sport. And there's a lot of discussions on the floor. The floors bounce back at them, like when they're pushing off and those things too. And I think, you know, if we think that tendons that have, that tendon that rupture has some kind of changes, but the tendonopathy with a pain might limit how you're loading it, it would explain because female gymnast, they can't, if you're going to land or jump off, you can't, either you do it or you can't do it, right? It's not, there is no level in between for those.So that could be that you actually get this high peak of the rupture. Yeah, okay.

Speaker 02772.76s - 2793.52s

Yeah, there's no protective mechanism from the, from the pain. You just, because, yeah, the floor is giving you so much. Yeah, that makes a whole lot of sense. So when we look at the kind of the mechanisms that lead to tendonopathy or the mechanisms that would lead to rupture, do you think they're, do you think they're different? Oh, this is a really good question.

Speaker 12793.62s - 2912.28s

We actually have part of a hypothesis that we're trying to do when we have funding for an animal study too, right? But is there a difference between overload tendon injuries versus overuse? And that is one of the things that we're thinking about, right? Because overuse, then, to me, would be a runner. You have the same body weight and you're just doing more and more repetitions and you don't have enough of recovery. Is that one pathway for tendonopathies versus overload would be, maybe you know,more repetitions, but you're just doing heavier and heavier weight, right? So is that a difference in the kind of changes that you see? So when you have the rupture, is that more of an overload injury versus teninopathy? Is that more of an overuse injury? And then if you think, I'm showing you with my hands here too,but is the young female gymnast a combination of overload and overuse why they're ruptures, right? And are people, if you're thinking about football, right? They're very heavy loads. They are increasing in weight. They're kind of really, really big. And it's a really heavy loading when you are what you're doing versus a marathon runner that has a competitive running over and over. Are there different pathways or are they the same pathways? And we're trying to look at that and see, I mean, right now for the model that we have, the overload that we're doing seems tobe more beneficial for you cut off the Achilles tendon and you look at what happens to Plantares PRODUCT that's more of an Achilles and C, but it seems to be hypertrophying with the overload, right, too. So it might be more, we might more have more of an exercise model than an injury model at this point. But I do think that those are interesting, right? And that might be different too, if you're talking about positional tendons versus low bearing tendons. But that's kind of where I'm thinking about. Are those differences and is there a pathway moving forward for that?I don't know. Did that make sense to you?

Speaker 02912.88s - 2961.24s

Did you buy that? Yeah. I'm curious if you've heard any marathon. I think it was one researcher or something on Twitter ORG was saying he ruptured his at the end of a marathon. And it did challenge my thing because I was always like, you need a very high load to rupture that I don't think the rupture comes from an overuse condition like in an acute setting.Then one of my other friends in a physio somewhere else, he was like, I think it's probably at the end of the marathon because he tried to sprint. And I was like, oh, that would make a whole lot of sense. Have you seen 10 Achilles ruptures in a state where it's not like a very, an overload, but just a overuse? Like probably there would be, they could exist.But for me, I'm like, I don't think that would really be a thing. I think you would need a very high load. Yeah.

Speaker 12961.38s - 3101.9s

And I think, yeah. And I think that's kind of,, it's an interesting question. The only time that it would be that kind of walking is when people have taken fluoroquinolones, right? Antibiotics and the tendons gone down. We see older adults that just kind of walk and the tendon ruptures, right? So then, but that's when you have a very weak tendon, so it doesn't really need a high load to be able to to get to that high peak, right?So I think that's kind of the key when we're seeing them to rupture. But otherwise, it tends to be some kind of overload and it's always that kind of mechanism, which brings me to something that I want to share with you too that I had recently, somebody reached out to me who was a physio and they, the mechanism of injury was playing, I don't remember, was pick a ball or whatever, right? And doing something quick. People around them heard the noise, heard those things, all the sign of the acute Achilles10 rupture went to the emergency room. Everybody, oh yeah, yeah, this is an Achilles 10 rupture, went to the emergency room. Everybody, oh, yeah, yeah, this is an Achilles 10 rupture. It's a classic case. They can, you know, maybe moves a little bit, but otherwise the Thompson PERSON test is positive. And then they send the person to the MRI. And then everybody reads the MRI and says, oh, it's not a complete rupture.It's a partial rupture. And then everybody changes. It's like, oh, we need other treatment. You can walk on it and whatever. And I'm like, no, the history where you had is absolutely an acute Achilles tendon rupture. Even if the MRI shows there's a few fibers left or whatever, that injury still should be treated as an acute rupture because the majority of it, even if there's something left there. Like,the benefit would be if maybe there's some fibers left, if that's a plantaris or something else. But you should not get, that's when imaging is bad, right? All of a sudden, the imaging, everybody was certain. He said he was certain. The surgeons were certain.You know, everybody was certain. And all of a sudden, MRI showed that it wasn't complete. And then they threw out everything they've seen, right? So the injury mechanism is perfect. that is a complete rupture should be treated like a complete rupture maybe non-surgical is better because if there are some fibers attached right so i think those kind of pieces is to really thinking about that as well i don't know why i that was important me was it was that

Speaker 03101.9s - 3106.56s

recent was there a follow-up on that that he that was probably within the last month

Speaker 13106.56s - 3112.12s

i don't remember when i spoke about i wonder how they're doing now if they if they treated it like that

Speaker 03112.12s - 3118.44s

and he could just say he could get back to things with only a few when he reached out to me and i'm like

Speaker 13118.44s - 3122.94s

no no no no no no you need to treat it as an acute acillist interrupture put your foot back in the

Speaker 03122.94s - 3129.18s

boot put it in plan a flexion and and literally reached out because he thought I was knowing things. So I think you

Speaker 13129.18s - 3138.94s

listened to that too. And I think finally, I think the treatment was treating as an Achilles end rupture, even though there might be some kind of fibers left too. Um, yeah, when you, so when

Speaker 03138.94s - 3149.62s

you have a similar, not, I guess not exactly similar, can people have that kind of ripple and that thing and just rupture the planteris? Is that a thing?

Speaker 13151.42s - 3165.46s

I don't know. I think I think you can rupture the planteris or you can rupture the tendon or one of them stays together and not too. In general, with that big forces and when you see the big ripple and things, this tend to be

Speaker 03165.46s - 3201.46s

the achilles tendon yeah yeah i saw when aaron rogers did his there was one doctor speculating that it might have been the plan terrace and uh hey but then it was it was not um so there was a there was a study i a long time ago and it was on achilles ruptures like they ruptured one side and then i think they did a 10 or 20 year follow-up um they compared to them to the general A long time ago, and it was on Achilles ruptures, like they ruptured one side. And then I think they did a 10 or 20 year follow-up. They compared them to the general population. And they saw like 170 times increased risk of rupturing the contralateral one over whatever follow-up that was.Why do you think that would be the case?

Speaker 13202.18s - 3205.34s

I think it was 300 or 400 times the risk ruptured.

Speaker 03205.48s - 3213.86s

Yeah, but those are ridiculous. So first of all, you have to put that in perspective to people, right? Because I happened to tell a patient that once, and I shouldn't have said that.

Speaker 13214.22s - 3223.18s

But the risk of rupturing in the first place is very, very small, right? So it's easy to double that risk. Do you know what I mean?

Speaker 03223.18s - 3235.32s

If it's infinitely small, now it's slightly more infinitely small, right? So if you depends, depend on how you describe it, you can say it's like 400 times more likely. So that's a different story.

Speaker 13235.98s - 3314.88s

But there are genetics reasons probably for rupturing. There are probably things if you had overuse or if your tendon was being used and have some degeneration, you probably have that on both sides, right? Because we're bipedal. There are other things that make the tendon weaker, like the systemic, maybe cholesterol, you know, prediabetes, all of those things.Those are systemically. So it's not surprising if one thing happens to one, that it can happen to the other side. So those are more of the body structure kind of genetic pieces that is not surprising, right? And the other thing is, if you were doing things that you ruptured the first one,if you go back to doing those things, you probably, you know, you're active on both sides. And then the third thing is that we know that you might not recover fully on that side, you might actually compensate using the other leg, right? So if I tend to push off with my left leg, but now that's a rupture side, I might gotten into pushing off more with my right, right?So those kind of pieces to it as well. So absolutely, I think all of those pieces together makes it easy to have a slightly more risk of rupture. But I don't tell my patients that anymore. But I've had a few patients with bilateral rupture. So of all the thousands I've had, there are a few. And, you know, it is what it is.

Speaker 03316.76s - 3338.12s

I had posted on my social media about Floricoin loans. And I had, I don't know, maybe 20, 30 people reach out with they. They took Floracinolones and I had I don't know maybe 20 30 people reach out with they they took fluoroquinolones and had severe tendon issues um what do what do you think about taking those like for you specifically if you had some thing that required an antibiotic would you not take

Speaker 13338.12s - 3346s

them knowing what you know or do you feel like that risk is so tiny well Well, no, no, that's not a tiny risk at all. Oh, it's not. Okay. No,

Speaker 03346.16s - 3353.22s

but fluoroquinolones are, if you can have antibiotics that is not the fluroquinolones,

Speaker 13353.22s - 3375.4s

there's a lot of various type of antibiotics, right? So you don't necessarily have to have the antibiotic that gives you that risk. Those are often used with upper respiratory and those kind of things, too. So if you're an athlete, I would definitely see what kind of antibiotics do you need, right? And sometimes I think they are more broad spectrum, but now I'm outside my comfort zone here too, right?

Speaker 03375.76s - 3380.48s

But if you can get with a doctor getting the antibiotics that you really need,

Speaker 13380.88s - 3441.6s

then, you know, that could be that you don't have to take those. On the other hand, if you're taking antibiotics, you're probably taking it for a very, very strong reason, right? So not taking antibiotics is not because I'm worried about my tendon would not be my answer either, right? But I would avoid fluoroquinolones, but you should also be very, very careful, right? We, you know, if you have on fluoroquinolones, I would not go to the gym and dobox jumps and do all these other things, right? You really, and it changes the tendon within eight days. So it's a really, really fast change, right? And then you can easily go and people, older adult can go from taking the antibiotics and then walking and pulse the tendon is ruptured. So not everybody that takes fluoroquinolones, the antibiotics ruptures, though, right? So you just got to be really, really careful. And what you've got to be careful, though, is loads that are really high, high loading rate, right?You want to be able to, you can do things, but high peak in speed and movement, that's when you get the high peak and load, and that's where you're going to be more vulnerable.

Speaker 03442.12s - 3442.88s

Did that answer?

Speaker 13443.34s - 3444.06s

Yeah, yeah.

Speaker 03444.68s - 3454.18s

Yeah, I was fascinated when I first saw those and then kind of the research on them. Do you know of anything else that has such a negative effect on tendons? Or is that like kind of one of the only things?

Speaker 13454.82s - 3473.16s

No, I mean, that's the one that is, I mean, that's a document and it changes quickly. And it's, you know, it's such a strong effect. And I mean, my only hope with that, that is, that's not good. But if we, if you know something can cause it that bad, maybe in the future, we can find something that can help tendon that quickly, right? You know what I mean?

Speaker 03473.24s - 3478.74s

To me, that is more fascinating, anything. But no, statins is the other one that people are talking about.

Speaker 13478.84s - 3502.62s

But that's, maybe like eight months. It might be some changes and things too. And I just spoke to somebody's like, oh, I'm not going to take statins because of my tendons. I'm like, well, you're taking statins because you have high cholesterol and that might be more of important for your overall health. Right. So, you know, it's that kind of balance of why you're taking things and how you're doing it too. And then corticosteroids has been the other part too, but that's probably, you know,

Speaker 03502.66s - 3509.52s

it's not that kind of risk as you see with fluoroquinolones. Yeah, they need to find the antidote from the fluoroquine alone.

Speaker 13510.02s - 3519.9s

Yeah. If something can make it that bad in a bit of time, shouldn't we find something they can do the opposite, you know, back engineer it, but yeah. Well, maybe that they need to mark,

Speaker 03520s - 3545.56s

they need to market PRP better. Maybe that's what they could, the marketing with therapy. So let's go on to, last one I got for you is on all of these adjuncts, because it seems like the thing with the tendonopathies is you got to get the loading right. Got to get the loading right. But all these adjuncts, you have like the heel inserts people can wear for insertional Achilles. I was listening to a few, unlike nitroglycerin patches, shock weight PRP,

Speaker 13545.72s - 3547.9s

what are, yeah, kind of, I guess,

Speaker 03548.74s - 3551.94s

where are your thoughts on all of these adjuncts for tendon pain?

Speaker 13551.94s - 3657.86s

So, sorry, I'm getting something down there. Yeah, I mean, I think that,I think we talked about a little last time too. I mean, sometimes the biggest thing with the tendon is that it takes time. And I don't think the tendon needs a lot more than a healthy environment and somebodypushing through and all that kind of stuff too. But a lot of times we need to entertain the patient in the meantime, right? So I think that's kind of where we go wrong a lot of times. We, you know, we talked about it just earlier, right? That you need to entertain the patients. I was just thinking, I was making sure I looked at one of my quotesin one of my, when I did my thesis, and it's from Voltaire PERSON, right? It's like the art of medicine consists in amusing the patient while nature cures the disease. That was in my tendonopathy. And I think that kind of still fits. So PRP, there is no real strong evidence that that will have anymajor effect or any benefit. There are equal just high volume injections and some people show with corticosteroid injections now too. So there's all these various things to kind of do, but the evidence is not very strong that is a benefit. I would not do PRP. I think it just cost a lot of money, but, you know, people, people feel the need of getting things done, right? I do then, having said that, I mean, there are some patients where I feel like you get to a point where it's just stuck, right? And that's what I think I mentioned the last time, too. Like,that's when I want my hammer. And sometimes you just need to jumpstart something, right? And that's what I think I mentioned the last time, too. Like, that's when I want my hammer. And sometimes you just need to jumpstart something, right? Sometimes we try to jump start it by changing the exercise program or we do other things too. So maybe for those people, some of those things kind of works, right? And that's when the scraping the tendon and

Speaker 03657.86s - 3666.72s

do all these various things. Yeah. Keep them entertained. Yeah. I mean, I mean, I'm sure you've seen that too, right?

Speaker 13667.04s - 3676.92s

We just need, you need the exercise. You need to load the tendon. It's going to take time. It's going to take six months. In order for people to do that, you need to kind of keep them excited to do that, right?

Speaker 03677.44s - 3694.08s

Yeah. Yeah. I, uh, when I had my pithola, I would ice, I was big on icing. I had like an ice cup and I'd ice it like four or five times a day, like 20 minutes, so it was basically numb. People ask me now and I don't think there's any negative and it probably is an entertainment thing. Are you in the same camp with the icing?

Speaker 13694.88s - 3729.9s

Yeah. I mean, you know, the ice, we don't think anything, we don't think anything negative is happening with it too, right? And I mean, the whole ice immersion now, too, is not that much of the data, right, in general. But I don't think that isn't. But however, eyes can decrease the pain. So you can get it numb to decreasing the pain. And that's not a bad thing, right? If you want to decrease the pain, I don't see that as a problem. And sometimes that helps too. And if there are some inflammatory or if you have Bursitis in there, I mean, some of those things that can really calm down. So I think people need to find what works for them. And if there are some inflammatory or if you have versitis in the air, I mean, some of thosethings that can really calm down. So I think people need to find what works for them and then

Speaker 03729.9s - 3737.68s

kind of do that. I don't see that as a problem. Yeah. So what's the new research? That's what

Speaker 13737.68s - 3815.52s

you're working on is the E-STEM, huh? Yeah, the electric stimulation is one of the pig pieces, right? How can we augment that? And I'm really interested in, we proposed a grant and they didn't like it at all. So unfortunately, but I'm also interested in the patella tendon and the quad tendon in relation to NioA, right? I think that that might be, I think the tendon might change early on. And then maybe that's why we see gate deviations and instability and things that are not explained. I think that might be occurring way before you see cartilage changes. So I'm very interested too that can we, but people say, oh, the people, they knee away,they can exercise regardless and they do better, right? Yeah, but not everybody gets better, but maybe they need more of a tendon loading, right, to get the tendons stronger in order to get them better. So that's another piece that we're really, really interested in. And then really interested in the metabolic aspects too, right? How does high cholesterol and prediabetes and are there people that we come to us that have more of the metabolic syndrome? Do we need to address the metabolic syndrome before we do exercise? Or is itfine to do exercise? And can they get better even if you don't address those pieces? So how can we kind of lay that out? Because there are people that are not as responsive. And maybe those are

Speaker 03815.52s - 3825.14s

the pieces that we need to get to. Are you speaking in Minneapolis, end of May? Yeah,

Speaker 13825.14s - 3827.1s

or Minnesota GPE, yeah.

Speaker 03827.1s - 3839.6s

I'm actually speaking the weekend before in Madrid GPE for the Isocanetic Conference and then I'm coming home and then I'm flying to speaking at the Tendon Conference in Minneapolis GPE. Okay, that's a few, it's a couple hours from meso I think.

Speaker 13840.1s - 3840.92s

Oh, you should come.

Speaker 03841.04s - 3842.94s

I think I might make it. Yeah, what are you speaking on?

Speaker 13845.12s - 3848.08s

Attendance. Okay. I think I might make it. Yeah, what are you speaking on? Attendance. Okay.

Speaker 03848.22s - 3849.92s

I'm talking about keynote clinical.

Speaker 13850.18s - 3876.82s

So we actually have a lot of my PhD students are coming to. We have a lot of clinical aspects to you. And there's some rotated cuff interesting surgical. And there are some keynote lectures relating to pain and tendon, which we know not a lot about at all. And then there are some clinical at all. And then there are some clinical translational. And then they have the multionics, kind of more of the genetic piecesgoing on in there too. And we're going to have some workshops and things too. I think it's going to be

Speaker 03876.82s - 3905.02s

really, really exciting to kind of see the range. You should come. Yeah. I think I will. I've never, I've never been to a lot of strength conferences and then I left strength and conditioning and now I'm about tendons. So I'm like, yeah, I think that would be great. I always try to find the presentations online, videos or the presentations. And it's so hard. Find like 10% of them. So it's one of those things you have to probably go there. We're in the middle of working we're a little of working on the schedule and stuff too.

Speaker 13905.32s - 3905.8s

So yeah.

Speaker 03906.06s - 3906.34s

Okay.

Speaker 13906.54s - 3906.74s

Yeah.

Speaker 03907.26s - 3911s

All right. Caren PERSON, tell everyone where to find you.

Speaker 13911.4s - 3921.44s

Well, where you can find me? I'm at University of Delaware ORG. I'm a professor here in the Department of Physical Therapy ORG. And you can always reach me by searching the website or then send me an email.

Speaker 03921.86s - 3926.34s

I don't answer the phones, but I answer emails. Yeah. All right. Cool. Thank you for coming on.

Speaker 13927.14s - 3928.54s

Thank you for having me.