Jill Cook
@ProfJillCook
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Physiotherapist, tendon clinician-scientist
La Trobe University
Joined March 2013
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We resolve symptoms not pathology
Symptoms return if capacity not maintained or load exceeds capacity
Educate the person on these things and they can self-manage
"Tendinopathy is not a problem that we "fix". All we can do is encourage our patients to manage loads and lifestyle until recovered and tho we can say many of them goodbye at 12 weeks, self-management doesn't end" -
@JeremyLewisPT
|
@ProfJillCook
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@BillingMartin
We do chronically underload MSK conditions
Several reasons;
physios often do not understand S & C principles,
are unclear about the load that exercises place on structures and
for me the key thing is that they HAVE NEVER BEEN IN A GYM THEMSELVES
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La Trobe University Australia in collaboration with University of Valencia have been awarded to 2020 International Scientific Tendon Symposium
September 2020
Excited to have the conference in Valencia, see all you tendonophiles there!
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Calf strength endurance a la Australian ballet essential for all lower limb tendinopathies
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Our preliminary data shows that patellar tendon pathology likely develops in adolescence. Other literature supports this concept.
Excess load disrupts normal tendon-bone maturation
Data from a larger cohort early next year
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Rules for twitter- tendons only, nothing personal, nothing political, always polite
BUT
I am breaking the rules this once because our wildlife needs help
The Bushfire Emergency Wildlife Fund is now live and accepting tax-deductible donations: .
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Absolutely no evidence for its efficacy in tendinopathy
Premier League medical professionals "caught between a rock and a hard place" over use of PRP injections
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Great effort from all involved and proud of what we achieved
Think it is the most up to date text on lower limb tendons
The
@FCBarcelona
x
@BarcaInnoHub
⚽️ Tendon Guide digital version now available👇
Editors:
@ProfJillCook
@gilrodasfont
@PrunaDoc
@Alan_McCall_
@lluistil
Rochelle Kennedy & >40 🌍 expert contributors. Incredible illustrations by
@DrawInNature
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All the calf work we push with lower limb tendinopathy is based on this excellent knowledge from
@S_Maysey
at The Autralian Ballet
@LinearProbe
@carlespedret
@AletheaSportMed
@tommymonkeybob
@JohnLeddyUK
@DrJN_SportsMed
V.common all ballet popns. In company, more common in younger, when they are developing resilience and strength. Surprisingly poor strength endurance.
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When we rehab a tendon we see changes in the tendon, the muscle, the kinetic chain and the brain
I do not think we know which of these is the most important, or if they are all equally important
@scotmorrsn
@ProfJillCook
@ScottEpsley
@TimWidderick
@Chris_Juneau3
@scotmorrsn
Just speaking to all of the potential factors that may affect mechanical change, other than what’s happening to the tendon material.
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Hi twitter tendon tipsters and trolls
Let me know what you think about this
I think it further defines the continuum model
And
Helps explain low grade inflammatory changes (occurs with IFM overload)
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Congratulations to DR Craig Purdam, awarded a prestigious honorary doctorate at La Trobe University!
Well deserved for years of service to physiotherapy.
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Read the journey of an athlete through patellar tendinopathy, great to have a perspective from the end user
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Makes sense
Tendons hate change so returning to high load after a period of unloading will always be dicey
@MayoClinic
@mayoclinicsport
Did the NFL Lockout expose the Achilles heel of competitive sports?
@Seth0Neill
See R Achilles Tendon Figure JOSPT:
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I have finally heard it all!
50 yr old man with insertional Achilles tendinopathy was diagnosed as having Sever's disease
Seriously people!
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Really???
Tendinitis and tendinosis???
Neither are relevant to healing times
It is pain that drives the recovery time independent of pathology
And how many tendon lacerations do we see, maybe rupture would be a better condition to have there
This is one of the better resources you will find on the web in relation to exercise prescription. Great job from
@DrChrisBarton
and colleagues and
@LaTrobeSEM
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AND stretching a tendon injury will usually make it worse
Following some great feedback here is the revised infographic for the myth..
'Not stretching enough causes injury'
Watch out later in the week for release of myth
#3
covering running shoe prescription and injury risk.
#runningphysio
#educaterunners
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Well now
This could be talking about tendon.......
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As expected, all musculoskeletal tissues will be vulnerable to injury after an extended layoff and a quick return to high loads
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@tomgoom
@BJSM_BMJ
@Seth0Neill
@pdkirwan
@DrPeteMalliaras
@LorenzodHont
@MikeReiman
@tendonpain
@PhysioMeScience
@function2fitnes
@DrChrisBarton
Using anti-inflammatory approaches for tendinopathy has never been helpful
We tried it is the 80’s and 90’s with no success
Rest, ice and anti-infammatories offer us nothing clinically in tendinopathy
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@BJSM_BMJ
For tendon pain, it is increase in pain the next day that is a flag for overload
During exercise only way to monitor is to ensure that load is the same or only a little bit more than usual load
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@GregLehman
@AchieveHealth
@scotmorrsn
@Bill_Vicenzino
Research cannot answer everything for a clinician
The clincian must integrate it into practice
Each study is only one piece of the puzzle
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Absolutely, stretching has no place in tendon rehabilitation
@ProfJillCook
@GregLehman
@PeteOSullivanPT
👍
Although I am much more likely to derive that compression tolerance via more task based approaches vs some static stretching.
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Kannus and Jozsa 1991
98% of ruptured tendons had degenerative pathology, other 2% had other pathology
Tendon strongest part of muscle tendon bone continuum, muscle tendon junction weakest ie muscle strain
That’s a great 👍 question
@ProfJillCook
! How do we know for sure that ONLY Achilles tendons with pathology rupture? What are the seminal references on this? Thanks 🙏 weighing in on this!
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@tomgoom
@pdkirwan
@Seth0Neill
@Seaniemc89
@ajmallows1
@DrPeteMalliaras
@DerekGriffin86
@rwilly2003
@RodWhiteley
Why do we need “food” for tendon?
1 there is plenty of collagen, just not right type or organisation
2 nothing make matrix structure “repair”
3 tendon lesions are tiny, we do not supplement for small skin wounds so why tendon
4 Pathology not linked to pain
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Change of shoes esp heel height can be linked to tendon injuries
🏃♀️🏃🏻♂️ Many runners believe that wearing the wrong shoe-type for their foot is a leading cause of injury.
👟 However, evidence is lacking for shoe prescription of any kind (minimalist, maximalist, traditional, or zero-drop) for the prevention of injury.
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@BJSM_BMJ
@michael_rowe
My experience with physios (when teaching) is that they are both passionate and committed to learning
They turn up regardless of cost and convenience to improve their knowledge and get better outcomes for their clients
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Tendons that thicken with overuse and pathology and those that don’t
Be really good to define if there are different tendon responses across the body
Cool study showing supraspinatus tendon remains thicker 6 hours after training in young v high level swimmers with a history of shoulder pain whereas pain-free tendons return to normal
Maybe shoulders aren't that different from Achilles & patellar tendons?
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@BJSM_BMJ
Tendon pathology is injured tissue, will have an inflammatory response
But it is not the driver of pathology or pain
And using anti-inflam measures makes no difference to pain, pathology or function
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Yeah
#nomoreclamshells
also for gluteal tendinopathy
Very low activation of gluts with clam shells
@mlyonspt
@Pelvicfloorexer
At Michelle Lyon’s fabulous Pudendal Neuralgia Workshop, Perth Western Australia
#Nomoreclsmshellexercises
as they may irritate the Pudendal Nerve
@DornanPeter
@exerciseworks
@apaphysio
@SandyHiltonPT
@EntropyPhysio
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Nailed it!
It has always been this message and not what has been suggested in the editorial
@Bill_Vicenzino
@ProfJillCook
@BJSM_BMJ
It's difficult to me to see any difference between the take home message of the articles and what
@ProfJillCook
generally recommend (and so the role of isometric) (see pics). Probably it's my fault, but it will be nice to have a different explanation.
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@tomgoom
@Seaniemc89
@GeoffreyVerrall
@MaartenMh
@BJSM_BMJ
Education is an essential part of rehab
Why they have not improved
What underpins pain and pathology
What loads are good and bad
How long it will take to get better and why
Why previous treatments have not worked
A key part of what we do
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@Barceruel
@blaisedubois
@tomgoom
@clinicacorredor
66% of those who rupture are not symptomatic but all have degenerative pathology (Kannus and Josza 1991)
You cannot rupture a normal tendon
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@InfoPhysioPT
The continuum model of course! Cook and Purdam 2009
Kannus and Jozsa 1991 tendon ruptures
Kjaer 2004 response of tendon to load
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What a great progressive overload program, just shows that load is key
Angel Basas does this with his Spanish jumping athletes each year as a prehabilitation for the season, also works really well
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I will be in Montreal Friday June 22 sharing tendon knowledge
Come along for the ride
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Similar to most other diagnosed tendinopathies where the source of the pain is not the tendon but from surrounding structures
"Tennis Elbow" is right up there as one of the most misdiagnosed and mistreated (⛔️cortisone) conditions in Musculoskeletal Medicine.
Especially as many are not tendon-related but ulnohumeral joint, radial nerve and sometimes cervical spine related.
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@FisioActual
@pdkirwan
@DrPeteMalliaras
@DelaTorree14
@function2fitnes
@FisioStacruz
@FisioPratoUS
@fisioterapianet
I would not use palpaton as a clinical diagnostic test in tendon pain
Eg patellar tendon is sore to palpate both in pfj pain & OA knee
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Same in tendons
70% of new shoulder injures occurs in beginning of pre-season. What do you do during off-season matters!
@martinasker
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@BRoe28
@Bill_Vicenzino
@MuscleScience
@jongumucio
New study by Docking et al shows both US and MR cannot pick a partial tear from tendon pathology (glut med tendon)
Partial tears over-diagnosed and over-treated
Treat as tendinopathy and load them
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@Javofisio
No treatment will return a tendon to normal
More importantly, intervening is not necessary for resolution of pain ie you can become painfree without changing pathology
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@BJSM_BMJ
@BJSMPlus
@SASMA2017
Clams do not activate gluts much at all, work by Charlotte Ganderton
Need to do other exercises
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@SoSimplehealth
@Retlouping
@mgibsonphysio
@DrJohnOrchard
Why are we even discussing PRP, the evidence is clear that is does not work for tendinopathy
And it shouldn’t: there is no underlying premise for why PRP should change tendon pathology
And that is not even considering that pain is somewhat independent of pathology
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@GonzaloGL_Fis
See Docking et al
Imaging is not able to distinguish tendinopathy from partial tear
Also there are no criteria for diagnosing partial tear and no established reliability
Clinically they should be managed the same, based on pain, function and expectations
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@BJSM_BMJ
@PhysioKTBrokerp
@Physiowizz
@physiopedia
@Bill_Vicenzino
Isometric for pain
Isotonic for strength
Fast eccentric = energy storage
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Deserved kudos to
@KarimKhan_IMHA
awarded Australian honours today for services to sports medicine
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@BJSM_BMJ
They often have to fail a few times before they get the message that there are no short cuts
Good education about need for time essential
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@kinesionerd
@Seth0Neill
Pain at night suggests another diagnosis other than load induced tendinopathy
Systemic arthropathy seen mostly at the achilles insertion
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Hmmm
Not sure bfr training helpful for tendons
Need high loads to change mechanical properties in tendons
Pre season / off season. Good time to use
#BFR
#bloodrestriction
training. Mimic physiological effects of high load training with low loads. Build
#strength
#hypertrophy
#endurance
without the risks
@Owens_Recovery
@Bfr_Solutions
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Interesting on many levels, the paper authors suggestion that some particiapnts only had bursitis suggests they do not even understand the condition
The Effectiveness of Platelet-Rich Plasma Injections in Gluteal Tendinopathy: Letter to the Editor
@Bill_Vicenzino
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@GregLehman
@scotmorrsn
@PeteOSullivanPT
I give up
If they have tendinopathy (tendon pain and dysfunction) don,t stretch
As they improve add necessary functional movements
Simple
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@sancho_igor
@Seth0Neill
@DrPeteMalliaras
@DrTaniaPizzari
@lorenzo_masci
That is the point
Every tendon is different
Every person is different
Every starting point is different
Every end point is different
You cannot standardise exercise in tendons
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Yep
Palpation soreness does not indicate pathology or correlate with symptoms
Cook et al 2001???
Not a useful addition to a clinical examination in tendons
@ProfJillCook
@Hewett1Tim
@MayoClinic
@mayoclinicsport
Are you saying that it Is impossible to rupture a normal tendon in vivo? If it does rupture, how do you know the prior condition of the tendon? I have palpated so many patient Achilles tendon for so many "non-Achilles" injuries, yet all were quite tender. Deep medial myo.
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Because the adaptation occurs in the normal tissue around the pathology
See Docking and Cook 2015 BJSM
If almost half of asymptomatic distance runners have Achilles’ tendon “pathology” on U/S imaging, and there is more “pathology” in those who had more years of running, why are we calling it “pathology” and not “adaptation?”
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All Scot’s work
Thanks to
@ProfJillCook
for the assistance on this one and
@UniVerona
for the open access option - a brief review of relative sub max lifting capacity and its implications for heavy slow resistance protocols
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So true for tendon pain as well
There is mounting evidence that poor muscle & joint health is a risk factor for worse general health. I believe we should treat people with joint pain and impaired physical function like we treat other chronic diseases: 1) Screen; 2) Monitor over time; 3) Treat early
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Thanks for letting clinicians know that there is a place for isometrics in the managment of tendon pain
Especially as you work with high level athletes and clearly have great management strategies
@ProfJillCook
We have had exceptional results with isometrics within our program specifically 4 PT pain management since 2015!
#GameChanger
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@KevinNordanger
@kgSilbernagel
@Seth0Neill
@DrPeteMalliaras
24 hour pain behaviour after exercise more critical than exercise pain. Stable pain OK-if increased pain a day later then decrease load
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@AdamMeakins
@scotmorrsn
@GregLehman
@Bill_Vicenzino
You know what?
Clincially we should be n=1 because it is the 1 that matters
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See recent papers by Peta Baillie and Sue Mayes that support the lack of correlation between OT on imaging and posterior ankle pain
Ouchy ankle 😩😫
Os trigonum & plantar enthesopathy with fractured ‘spur’
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@FAMS_SE
@LinearProbe
@Seth0Neill
Muscle strength and power the key intervention in treating tendon pain and dysfunction
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You know what I am looking forward to most from this thread?
Supportive twitter from great women whose sole aim in life is NOT to pull other people and their research down
@devrajoyPT
@Physio_Rachel
@gitaramdharry
@physioralph
@NicolaJHancock
@JudithDeutsch
@JHaleATX
@proskoyoga
@karenlitzyNYC
@GregLehman
@affectivebrain
@ProfJillCook
@ProfCaraLewis
@MaryOKeeffe007
@ewa_roos
@Farmer_MindBody
@FionaWilsonf
@IzzyMoorePhD
@Nayra_Rabelo
@kgSilbernagel
@kaymcrossley
@soccerPT11
@clare_ardern
@adiemusfree
@MaxiMiciak
@NicoleStoutPT
@Nim_Perera
@yegphysio
@jwhittak_physio
@LKTphysio
@ekstokes
@rtholopainen
@sfosterpt
@emmaseppala
@self_compassion
@BreneBrown
@TheErinCalipari
@TerryEllisPT
@choo_ek
@SueLord_Neuro
@shereebekker
@jbezner
@DrJenGunter
@RachelToovey
@AliciaSpittle
@jenny_mcginley
@TaraLFitz
@pip_nicolson
@kwong_amanda
@kate__cameron
We need more women scientists in the public sphere. We need to amplify the voices of women, show the amazing work they’re doing, and change the idea of what a scientist looks like. And that's exactly what you're doing with this brilliant thread!
#WomenInSTEM
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Eeeeeekkkkk
We have come a long way, both in research design and in understanding..............
Throwback Thursday and FREE. Curious as two what we have learned about patellar tendinopathy in the last 23 years? This was cutting edge in 1997.
@ProfJillCook
@AlphSportsMed
@LaTrobeSEM
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Suki, do S&C coaches use isometrics when managing tendon pain in athletes?
I am immensely proud to have won the "NBA 2019 Strength Coach of the Year Award" voted by my peers! This is a huge achievement for our Perf. Dept + I would like to thank
@the_nbsca
for welcoming 2 foreigners with open arms into the League 4 yrs ago!
@MichaelDDavie
@Bucks
U ROCK!
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Or overuse tendinopathy
Palpation not a valid measure of enthesitis in inflammatory or non-inflammatory pain conditions.
@ProfJillCook
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@fisiocorb
Haglund morphology does not need to be treated, use heel raises high enough to remove tendon compression against calcaneus, raises may need to be 3-4cm high
Add tensile load in heels ie without compression
Short wave has no evidence and unlikely to help
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@PhysioMikeS
@fisioterapianet
@DrPeteMalliaras
@DrChrisBarton
@mickwhughes
@Bill_Vicenzino
@pdkirwan
@Seth0Neill
@AdamMeakins
@ThePrehabGuys
@FisioPratoUS
@LaTrobeSEM
@acea_ngel
Imaging adds very little in terms of diagnosis, prognosis or effect of rehabilitation.
Imaging not linked to symptoms
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@sancho_igor
Friction causes issues like other loads when there is an acute change in the amount the tendon is exposed to
Classic example in Achilles is excess PF and DF eg unaccustomed cycling
Tendons hate change
If you have to change loads, do it slowly
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@BJSM_BMJ
@LaTrobeSEM
Thanks for the early opportunity for female non-doctors to have a say in the sports medicine academic publishing process
Foresight......
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@LauraOpstedal
Strap will compress mid-tendon where there is no pathology
RCT shows no important benefit of strap
Use if helps pain & improves loading
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@davebakerphysio
@LinearProbe
@ACPOMIT
@thecsp
@ESPPNphysio
The answers are likely
Why-no logical reason for most injections
When-never
Where-never in the tendon
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@PainSci
Tendons do adapt well to compression as that is a load they sustain at the bone tendon junction.
But pathology here common as well
Rat model shows compression by itself not provocative but combinations of compression and tensile overload is
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@tavisbruce
We tend to use leg press as a bench mark, expect athlete to do 1 - 1.5x body weight for 4sets of 8reps. Single leg, not full range approx 10 - 80 degrees
Some sports expect more
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@davidkeenePT
@DrPaulDijkstra
@Oxford_Trauma
@RRIO_news
@OxfordBRC
@ndorms
@OCTRUctu
@NIHRresearch
@OTrauma
@PhysioATOCP
Results make biological sense
A rupture institutes a massive inflammatory, proliferative, maturative response resulting in tendon repair
No need to add any other stimulus
Same results in rotator cuff repair
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Excited you are all excited, hoping to have Spanish translation for the conference as well
#tendonworldconference
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@AdamVirgile
@kgSilbernagel
@KThorborg
@MichaelRathleff
@BJSM_BMJ
@MathijsvanArk
@SIDocking
@HansZwerver
@AVSportSci
@_JSAMS
Tendon pathology does not heal, so there is no way isometrics take away this important message
Progressive strength underpins tendon rehab, isometrics are but a small part of it
this editorial is disingenuous in several ways about the role of isometrics for tendon pain
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@bellkneesurgeon
Tendons classically worse the next day if load exceeds capacity
On loading test and on hallmark signs
eg hop and morning stiffness for Achilles
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@Seth0Neill
@Bill_Vicenzino
@sancho_igor
@DrPeteMalliaras
@DrTaniaPizzari
@lorenzo_masci
@PeteOSullivanPT
You miss a key point
Eccentrics are a 12 week rehabilitation program to treat tendinopathy
Isometrics are a treatment to relieve pain WITHIN a structured and progressive rehabilitation program
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New scholarship based at La Trobe Sport ans Exercise Research Centre AND The Australian Ballet
Investigating foot function in dancers and athletes
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Agree
Knowledge of the clinician and education of the patient the only options to tackle the use of interventions that lack an underlying scientific premise
@ProfJillCook
This is a very difficult message to share with pts I’m sure you’ll agree. We are challenged by quick fixes of injections and surgery and promises of easy answers. Tough times.
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@floteichert
@DrPeteMalliaras
@kgSilbernagel
@HakanAlfredson
None whatever
You are probably told it stimulates collagen and blood vessels and helps repair
None of that is true
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@KThorborg
@SIDocking
@CraigLiebenson
@AdamVirgile
@kgSilbernagel
@Bill_Vicenzino
@MichaelRathleff
@MathijsvanArk
@BJSM_BMJ
@PeteOSullivanPT
@PainRevolution
@kieranosull
@jpcaneiro
@MaryOKeeffe007
Nobody ‘focuses’ on isometrics
It is the best way to get people to buy into an exercise program as they can see immediate benefits
You misrepresent how they should be used
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@Thomas_Arends
The literature has many papers showing both positive and no benefits,I think depending on your bias you can support either side of the argument.
I think there is a time and place to use it, but a clinical reasoning process in its use is lacking
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Be there!
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@AshisArmyPhysio
Confirms what we already know
Anti-inflammatory treatments are not helpful in the management of tendinopathy
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@Retlouping
@MKDEabh
@BobVermeeren
@GregLehman
Clinically no, if tendon imaging normal then look for another diagnosis
So many structures masquerade as tendon pain, a good clinician can sort this out
2 key signs of tendon pain
*localised pain that stays localised
*load dependent increase in pain
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@BJSM_BMJ
Sorry, no clarity here, ask clinicians and patients if they help
Do isometrics help tendon pain?
Yes
692
No
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@sports_med_doc
@lorenzo_masci
Correct diagnosis
Decent conservative management
Time for tendon to adapt to higher loads
Little else needed
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Could we include physiotherapists as key providers in this space as well?
Completely agree
@DrJohnOrchard
- Government subsidy is key for cancer patients accessing more clinical exercise services - currently the five CDMP sessions is awfully insufficient, and cross-allocated with other allied services.
#TimeForChange
#ExerciseOncology
#ExerciseMedicine
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@DanG_sportPT
@TPMPodcast
@PhysioChris
@alisongrimaldi
@JeremyLewisPT
@tendonpain
@SIDocking
@Seth0Neill
Isometrics are for tendon pain
Only at the start of rehabilitation
Only a small part of tendon rehabilitation
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Think it is the old wringing out theory because of tendon rotation with pronation
Shown to be incorrect and tendinosis is hypervascular
@AmitLakk
@northwoods1980
@samrad77
@lorenzo_masci
i don’t understand the use of ‘ischaemic’ terminology - it keeps cropping up - doesn’t accurately represent underlying pathophysiology of tendinopathy
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@tomgoom
@Seth0Neill
@DrPeteMalliaras
@lorenzo_masci
@pdkirwan
I think the thing that is often not done well is the size of the heel raise during conservative management
For me 3-5cm essential (enough to make walking painfree) for weeks
Not seen many good outcomes after surgery - slow and never back to full activity
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@AdamMeakins
@scotmorrsn
@GregLehman
@Bill_Vicenzino
Then you should not be a clinician if you cannot do what Sackett said
Balance patient and clincian needs with the evidence
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Think in tendinopathy there is such a clear relationship between load and pain people learn quickly to stop loading
In other MSK pains the realtionship is not as clear, hence kinesiophobia less powerful
@ProfJillCook
@honest_physio
@AdamMeakins
@tomgoom
@DerekGriffin86
@MaryOKeeffe007
@GregLehman
@CorKinetic
@function2fitnes
@JackAChew
Is it fear of motion ie kinesiophobia or fear of painful movement? Do we have a way of distinguishing the difference?
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@MovementPainPT
@BJSM_BMJ
@kieranosull
@RodWhiteley
@Seaniemc89
Those with lower limb tendon pain have kinaesiophobia from pain with movement and a poorer QoL because they cannot be as active as they want
Not sure there is much more too it
AND if you improve their function they get better without too much else
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@AngeloCacchio
@DerekGriffin86
Only loading will increase capacity of tendon to tolerate load, passive treatments have no long term effect
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The quadriceps tendon is, which we know
Unlikely to be a big player as should suggest that most problems would occur in deep knee flexion as with the quads tendon
Is this evidence that the patella tendon may have a compression point (bony cam) against the tibial plateau? Quick glance suggests so (watch side view).
@ProfJillCook
@DrPeteMalliaras
@Bill_Vicenzino
@JarrodAntflick
@fizziowizzio
@pdkirwan
@CPurdam
@philglasgow
@thekneeresource
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