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Physio Foundations episode 2

Foundations of tendinopathy: with Peter Malliaras

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Welcome to the second episode of Physio Foundations, a podcast about the knowledge and skills that provide the foundation of expert physiotherapy or clinical practice.

In this episode I talk to tendon expert and researcher Associate Professor Peter Malliaras from Monash University about how he built his foundations in physiotherapy practice and research and the most important things to consider for people with tendinopathy.

 

In this episode:

0:00 Introducing Peter Malliaras

2:05 Find your passion

2:44 Work with people you admire and want to work with

3:30 What are the fundamentals of tendinopathy?

4:50 Old ways of treating tendinopathy, oh my...

5:30 Be critical of your practice

6:30 Goals of management of tendinopathy

8:30 Why do people get tendinopathy?

11:10 Look broadly at the problem and the person

11:55 Foundations of physical examination

14:10 Avoid confirmation bias

16:05 People who measure and people who don't measure

18:30 Not everyone with tendinopathy will be weak

20:12 Prognosis. Who goes well, who takes longer? Psychosocial factors

23:20 Look how far we have come

 

View Peter's research profile here

Peter's tendinopathy website

Connect with Peter on Twitter @drpetemalliaras

 

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EPISODE transcript

Note: Physio Foundations is available as an audio and video podcast on the Perraton Physio YouTube channel. You can access closed captions for available episodes on YouTube or review the audio transcript below. Transcripts are generated using a combination of speech recognition software and human transcription and may contain errors. Please check the audio before quoting in print.

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0:00

On the very first episode of Physio Foundations I'm talking to Associate Professor Pete Malliaras from Monash University about the fundamental knowledge and skills that you need as a clinician, physiotherapists, physiotherapy, student, to help people with tendinopathy

0:11

Welcome to the Physio Foundations podcast. It's a podcast about the foundational, fundamental knowledge and skills that underpin expert clinical practice.

0:25

I'm your host, Luke Perraton, and on the very first episode of the Physio Foundations podcast, I'm delighted to announce my guest is Associate Professor Peter Malliaras from Monash University.

0:38

So Pete is a colleague and friend of mine at the university. We work together on various research projects, supervising research students and in teaching, well, he's the perfect guest to have on first for the podcast.

0:52

So Pete, thank you and welcome.

0:58

Peter: Thank you very much, Luke. Thanks for having me.

Luke: Great. So let's just go into your current position first.   Just tell the listeners a little bit about yourself, what you currently do and your origin or your foundation story.

1:07

Peter: basically I pretty much went into research quite early in my career and was fortunate enough to work with some good people tend to not be.

1:24

The tendinopathy space is quite small. So once you start researching that area, you meet a lot of people very quickly and working with all these people that you read their papers and just sort of admire their

1:41

work was a really good experience and that was during my Ph.D. and then that sort of mushroomed into going overseas to the UK.

1:50

And I think in terms of I mean doing a PhD is one thing, but making it into a passion post-PhD is a different thing and that's probably the thing I want to highlight what you then have to do almost harder work post PhD to to focus on that area to learn as much as you can via the literature, but also work with the best people in that field.

2:21

And so I went overseas and did a postdoc with people who were doing a lot of tendon research and like Professor Nicola Maffulli and Dylan Morrissey.

2:24

And that turned out to be probably the I would say the the turning point in terms of learning for me. And that concentrated time five years in the UK, I worked in tendon clinics where we would just see tendon patients with a whole group of experts from different fields.

2:50

And that that experience was probably the thing that I learned the most from and that I sort of then was able to go into the sort of career that I have now.

3:03

Luke: In this episode, we'll go into the knowledge and skills that that you really need as your foundation, 

if you can be helping people with tendnopathy. But it is important for the listeners to know who they're listening to and where you've come from. So let's get into the specifics here. So what are some of the most, you know, all that learning you've done over many years?  What are some of the most important things that physios and physio, students or other musculoskeletal clinicians should know about or think about as they go into the clinic, if they're going to manage to help someone manage tendinopathy?

3:46

Peter:  It's a really good question. It's an it's one that sort of makes you stop and think because it's in one way you can sort of think about it.

3:53

It has a lot of musculoskeletal conditions that we treat treated with similar principles.

4:03

So if you treat them, we're trying to educate people and empower them about the condition, how to manage it,

4:10

and trying to lay their fears and then try and set them on the right path with activity and with exercise.

4:18

So turning up the I guess the principles are very, very similar, but so I guess getting the basics right is the first probably lesson for a new grad.

4:25

I'm just trying to think back when I was a new grad,

4:41

I remember distinctly working in a practice in North Melbourne and I distinctly remember sitting in a room and doing ultrasound,

4:44

therapeutic ultrasound as well as our frictions for tennis elbow.

4:54

And I've got this visual memory of it that just, you know, haunts me, I guess you could say.

4:59

Now, I told the Monash physio students recently the same story.

5:04

Yeah. Yep. There was an ice involved as well I think in that advice to do nothing and rest.

5:09

I think there was all sorts of wrong things happening 25 years ago.

5:16

That's right. And it takes me back to like the way my thought processes were at that point.

5:20

It was basically very uncritical and I would think, okay, so I've been taught in second year or whenever it was,

5:26

you've got to do this protocol, the Spanish and Korean protocol it was then you've got to start with this stretching.

5:34

You've got to go into this, then you've got to go into this eccentric exercise,

5:40

then you've got to finish off with ice and fractions or whatever it was. It's probably not right,

5:44

but and I just uncritically just followed that like a robot and then I and that takes me back to sort of my thought processes.

5:48

So I guess, I guess for a new graduate, the, the think about think about the basic,

5:57

basic principles that you're trying to achieve with a patient who's got a tendon problem.

6:08

And really what you're trying to achieve is you're trying to determine make them feel more comfortable in terms of the pain.

6:15

And that will come from talking to them largely to allay their is that's probably the most important thing,

6:22

allaying their fears, setting their expectations, allowing them to understand what they should and shouldn't do.

6:29

If you're doing that, you're doing you're doing a fairly good job already, much better than what I was doing at that North Bay clinic 25 years ago.

6:35

But then if you can go beyond that and start thinking about exercise and doing some exercise, that's going to load the tendon as well for, you know,

6:44

starting off from a point of view of trying to set something that's going to

6:56

be suitable for them based on how much symptoms they have and their function.

7:01

I think those basic principles,

7:05

if you're applying them in a critical way with with with a sort of idea of who who is in front of you rather than a cookie cutter sort of way,

7:06

I think that is, you know, really a good starting point for for new grads to be critical of what your you're doing and what you're

7:17

thinking in your thought processes and and always bring yourself back to those basic principles.

7:26

And it's interesting that you started with education and laying fear and then you started talking about exercise,

7:31

and then you've already steered us away from the dinosaur days of, you know, icing and doing transverse frictions and ultrasounds and things.

7:40

You know, all the listeners know that that's what used to happen and that they've ended up with the research field has moved along so much.

7:48

But it is interesting to reflect on, you know, where we've come from and definitely don't go very oh,

7:56

in a way, those days were simple because you just had your recipe.

8:04

You go into a clinic, you apply your recipe, you do your stuff and you go out and you don't have to think too much.

8:08

But also there was a whole stack of confusion because you're thinking, am you always thinking, am I doing the right thing?

8:14

Why am I doing this thing that I'm doing? So thinking critically, I think deeply about everything you're doing is, is really important.

8:21

Mm. Well, let's take a step back and talk about why people get to in apathy,

8:30

because that's going to be fundamental to the treatment and the assessment and the treatment you do.

8:36

So what are some of the causes and contributing factors?

8:41

I know that's, you know, quite heterogeneous and there's lots of different causes and contributing factors, but generally the the.

8:44

Probably the biggest one is just activities and changing activity to show people.

8:53

But if we talk about lower limb and starting to use your arms at work or overhead activity,

8:59

repetitive activities like sport or tennis or other things can bring on a tendon problem with a lower limb.

9:07

It tends to be repetitive, stress shortened cycle activities.

9:15

There could be things like walking or it could be things like running any sport activities.

9:20

So I think the starting point,

9:26

from a point of view of understanding a tendon patient is trying to understand how much loading they're doing in those in those sort of domains.

9:29

So you've got to understand how much torque, what type of load and how much they're putting into their tendon.

9:38

And then you've got to that's that's a starting point for then thinking about do I need

9:46

to be thinking about reducing their load or increasing their load as part of treatment?

9:52

But then there's other risk factors like the person's general health.

9:59

So they might be might be that they are a smoker and they've got diabetes.

10:03

So that could increase their risk of and also make it poor prognosis for getting better.

10:07

It could be that they've got their female menopausal type period, which is going to be also possibly a risk factor.

10:13

The other major ones are metabolic disease, metabolic hormonal changes in females.

10:26

They really are the major ones. They really are the major ones.

10:34

There's not a lot of evidence that say if you've got really poor biomechanics or you've got really poor strength,

10:37

that that's going to be a risk factor. There is some, but there's not a lot of evidence for those and it's quite variable.

10:44

And I think that's why the evidence is not clear because for some people, strength might be a risk factor.

10:50

For other people it might not be at all. So it's quite variable and we don't really have a lot of certainty on those.

10:57

But again, go for the major ones, go full load and really explore that and then look at any major general health issues as well.

11:03

So what I'm getting from that is the lesson here is to obviously we're not here to tell

11:13

clinicians and physio students how to do an initial interview and the structure that.

11:19

But just to just perhaps to think from the perspective of an expert how we can look

11:23

more broadly at the problem and the bigger picture as well and think about the person.

11:29

So, you know, if we get to the end of our initial interview here and with considered contributing factors and causes and you

11:35

know perhaps not as strong a links between some of the as a strength for example and as a contributing factor.

11:45

What about when we get into a physical examination and look at impairment?

11:53

So what are the main impairments you see when you measure things?

11:58

So the main one is that people present with pain.

12:04

So pain is the biggest one.

12:11

So we need to be measuring that in a, in a, you know, in a way that we can then sort of look at how it's changing over time.

12:13

So get into the habit of assessing pain scales.

12:23

So it could be a how much how much pain what's the worst pain you've had over the last seven

12:29

days or how much time do you have with a hot test or with a squeezed maximal grip test or,

12:34

you know, those types of things?

12:42

So pain is a really important one, but the other impairments are things like generally a lot of people will have motor impairments,

12:45

so they'll have reduced strength on their affected side.

12:56

And again, you want to get into the habit of trying to measure those.

13:03

And it could be that you just do tests, like repeated tests that will give you some idea of their endurance.

13:11

Or it could be that you've got a John a moment and handheld on and you can measure them that way.

13:18

We're getting more and more, I guess, high tech with how we measure things, and that's very, very important.

13:24

So as a new grad, you want to be thinking what's what's and again, critically, critically think through things.

13:31

How do you know that someone has got a strength impairment?

13:38

Is is the test that you've done reliable enough and valid enough to be able to tell you that?

13:42

And if you've just done a sort of. What do you call it?

13:50

A maximal sort of hand pressure.

13:54

Resisted. Resisted with your hand. Manual muscle test.

14:00

Manual muscle testing. It may not be reliable or valid enough to actually tell you if there's a difference or if this person is weak.

14:03

So that's important.

14:12

You don't want to fall into the trap of something like a confirmation bias type trap where you're thinking, this person's got a tendon problem.

14:14

They're likely to be weak. I'll test my I'll do a menu.

14:24

Muscle test. Oh, look, they are weak. That's it.

14:28

I'm going to fall into that trap because that that's a that's a classic confirmation bias track where you're not using the right tools.

14:31

Not everyone with tend to not with you will be weak not if not all of them will need a strength program in inverted commas.

14:39

So it's I think it is important to to think about, you know, how are you arriving at your answers?

14:48

And the same thing with diagnosis. How do you how what gives you certainty that that diagnosis is the right one?

14:55

Help give you certainty that those impairments are reliable.

15:03

So those things are important to think through.

15:08

So talking really generally about upper limb and lower limb tendon empathy, but just generally so we've talked about pain,

15:13

thinking about pain during a functional task, for example, a heel raise or a grip strength test.

15:19

Kind of the last seven days. And then also measuring strength.

15:27

Consider ways of objectively measuring strength and then thinking about how much error is likely to be in that measurement of strength.

15:31

Anything else that you would see in the foundational, fundamental management of tended empathy in terms of measurement,

15:39

things that you have to track at the impairment level, at the functional and participation level later on.

15:47

Pain and strength a big once you have pain and strength, you can talk about function if you like as well or anything else that you'd measure.

15:56

I deal with measurement basically as much as you can.

16:03

I think that's what is going to separate us apart in the future.

16:09

People about measurement, people that don't measure up because it's becoming much easier to measure things in the clinic.

16:14

So in the clinic now, with an Achilles patient, which is the cohort that I specialize in, I'm able to measure maximal voluntary contractions,

16:21

rate of force, develop,

16:33

and even helping type metrics like looking at how they how they hope from a point of view of how they how efficient they are with.

16:34

When you're able to do these relatively cheaply. So all these things are possible.

16:47

Now, that might not be something that every clinic wants to or can set up, but you can certainly look at the literature and find a robust,

16:54

reliable and as valid as you can within your budget and within your clinic scope

17:06

measures that you can use for strength and for functional things like helping.

17:12

So for example,

17:17

helping you can use apps that are pretty cheap that allow you to measure things like even vertical stiffness and hopping height and things like that.

17:17

So these things, these functional things, again, get into the habit of measuring as much as you possibly can.

17:26

It's good for your own learning.

17:35

You might be surprised sometimes to find that the deficits that you expect are not there, but it's also good for the patient as a motivator.

17:38

If the deficits are there and you then sitting in a program to have to see that,

17:46

to stick to and you sort of you've got the evidence that you're not guessing,

17:50

you're not saying, Oh, I think you're weak,

17:55

therefore I'm going to give you this is saying I know your way because we've got this data that's telling us you're weak.

17:58

I'm going to say this and then we're going to look at this number going from here to here in the next few weeks.

18:04

Goal setting and motivation. Exactly. Exactly. And that makes a huge difference for patients and also for your own enjoyment.

18:10

I find it so satisfying to be out of sight of patients.

18:17

This is your this is what I've clocked you at and this is what I want you to be at.

18:21

And this is this is how we're going to achieve it. So it's it's really satisfying if you can do that.

18:25

Hmm. And look, the key point you made earlier was not everyone with tendon apathy will be weak and they may not need a strengthening program.

18:30

So looking beyond the things that you think will be a problem and actually measuring and yeah,

18:39

getting lots of data points for hundreds, even thousands of patients over your career ability.

18:46

Garron Bank of clinical evidence. Exactly, exactly.

18:51

And that's that is really what it's about because if you can have then the discussion about what do trials tell us,

18:54

trials tell us about the average person.

19:03

So this is how the average person is going to respond to an exercise intervention, but it doesn't tell you about your patient in front of you.

19:05

And it may be that your patient in front of you because of your experience, you you can start to think that they might be need something different.

19:14

Not not so much. Not so much. This we know that exercise works for the average person, but this guy is really strong.

19:22

Has tried it all before. It's failed. Maybe I'm going to give him something different.

19:30

So it's it's a it's a really good way to think that you're working in an

19:35

environment where you can just get evidence from every single patient you see,

19:39

and you can use that to then inform all the other patients you see in the way that you treat it.

19:45

Back to your original point about being critical and thinking about what you're doing rather than just applying recipes?

19:50

Yep. We're going to wrap up part one in the minute. We've got part two.

19:58

We're going to record part two and release part two separately of this chat.

20:01

And the structure for this podcast is going to be the foundational, fundamental skills and knowledge.

20:05

And then we'll go into a part two with guests where we're going to talk about the more advanced scope progressing your knowledge.

20:11

So look, we'll say that some more advanced concepts for the next part of our chat.

20:17

But in terms of wrapping this one up prognosis, generally everyone has a different prognosis and it's there's not one answer for this,

20:22

but generally who goes well with tendon apathy? Who takes longer?

20:31

Is there anything that triggers you to think, okay, there's a bit of a red flag or potentially we can have a slower prognosis.

20:35

They may not respond to treatment right away. Perhaps a double barreled question here.

20:45

There could be pitfalls that clinicians could look out for in terms of prognosis if people aren't going to respond to treatment.

20:50

What do you think? I think that it's it's probably it's probably true to say that the classic variables

20:57

that people think about for prognosis like are you've had it for ten years or,

21:10

you know, duration of symptoms or even things like BMI.

21:15

They don't really relate to prognosis, especially if you look at them in the research that there may be some evidence that they prognostic,

21:20

but not a lot of the variables that haven't really been investigated a lot are some of the starkest psychosocial wearables.

21:27

So it's getting into sort of determinants of health chart sort of area.

21:38

What impact do these psychological variables have?

21:43

And I think they do have an impact. So if you're if you're much more attentive and stressed about the pain, it's going to have an impact,

21:48

most likely on what to do and that those sorts of relationships are starting to be untangled now.

21:58

But we're sort of a long way of really understanding the impact of those variables.

22:04

But they have been probably not studied enough up until now, and we're starting to get more evidence.

22:09

So so those are the ones that I look at a lot, but you must look at everything like strength.

22:16

Again, it's that sort of individual approach. East Are they really weak?

22:22

Is that going to be a problem for them getting back? Are they really stressed and anxious and fearful?

22:26

Are they really unhealthy and overweight and is that going to be a problem?

22:32

So they're the sort of domains that you might consider very multifactorial, very individualized for different people, I think.

22:37

But as long as you're critical thinking to yourself, you know,

22:44

what are the potential factors for this person in front of me that might just think about on the logical level logically,

22:48

what if if this person was going to do an exercise program, what factors would predict them not having a good recovery or getting stronger?

22:56

And you could think about it the same with pain. Pain is much more complex than just getting stronger.

23:04

But what is going to impact their pain, not improving?

23:09

Could it be some of these factors as well? So yeah, that's sort of the way that I would think about it.

23:14

You know, we've come a long way from icing and stretching and transverse frictions of tendinitis to your psychosocial management of tendon.

23:23

And you know, you've taken this really nicely on not just the current thinking of an expert and the foundations of your expertize and your thinking,

23:36

but also on the bit of a journey of why current practice is as it is.

23:45

So thanks Pete. Really, really interesting.

23:51

Really nice. Episode one Thanks for helping me break the ice.

23:54

I can come back in and do a full episode on frictions and if you like.

23:58

Yeah, good. We'll do that just for to be shock jocks, just people listening and then we'll go back to the, the stuff that works, but sounds good.

24:04

Oh, so now I'm going to be putting your details where I find you on social media, etc., all in the show notes.

24:14

So we won't say them here. And we'll wrap up at the end of the second episode, which is progressing your skills and knowledge.

24:21

Part two. So stay tuned. Listen to part two with Pete for now.

24:28

Thank you very much, 

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