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Physio Foundations episode 3

Foundations of tendinopathy 2: with Peter Malliaras

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Episode details

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.


On the second episode of the Physio Foundation's podcast, we're joined again by Associate Professor Peter Malliaras from Monash University. 


And this is part two of our conversation.  If you haven't listened to part one, which was the foundational knowledge and skills of an expert in tendon empathy, go back and listen to that.


First, we're going to continue the conversation. And in part two of the conversation, Peter and I are going to talk about progressing the next level of knowledge and skills in tendon empathy.


So, Pete, thanks for joining me again. Thank you very much.


Let's go straight back into it. So in the last conversation, we finished up talking about prognosis and the people who perhaps have a less favorable response to treatment and those who do better. 

And there was a lot of questions left unanswered. So let's go and talk about those in more detail.


So you often see people in the clinic, in your roles. You're a clinical expert and a researcher in tendinopathy,  It's fair to say that you'd commonly see people who have tried various therapies. 

They might have seen other clinicians, and then they're seeing you. So where do you start?


Peter: I think it's a really good question because it's you don't you don't want to ever be too confident.


That's that's always been my I guess I am a researcher because I'm not confident in my knowledge,


because I think when you are overconfident and you think, you know everything, what happens is you're not critical and you're just basically applying stuff that you think is right.


Maybe it's not right. So I think when someone comes in and they've tried everything, the worst, pretty much the worst thing you can do with them speak.


I think this is just my opinion, but be too confident and say, I know what's going to fix you.


You haven't done this. You have to sort of give them the benefit of the doubt sometimes and say, look, you've done exercise, you've tried it.


It's possible you haven't done it for long enough. It's possible you haven't done it intensely enough.


Maybe it's maybe you have and maybe we're not going to get a good response with this.


But what I can suggest is that you try you may think to yourself, you know,


that I'm telling you stuff you've done already, but let's see if you know, just tell me if you are.


And this is the approach I take. Tell me if you are. But have you done this and this in this, this and this way?


And a lot of the time people say, no, I have them.


Sometimes they'll say, Yeah, I think I have. And that and I say that all the time because I see people who come in and I mean,


sometimes patients come in and they basically are regurgitating the program that I would set them


because of physios come to one of the courses that I do and they've had the same program now,


probably set them. So I'm not going to go and repeat that program for that person.


We're going to look at other options. So we've got I think you do have to.


Yes, we all think we can we can get people better and we can all because otherwise we wouldn't be doing it.


But we also have to be conscious that exercise is not a panacea.


It doesn't work for everyone. We can always get people better regardless of our best intentions.


And I think if you accept that, you can then start to think about other options and involving other clinicians.


So it could be sports doctor colleagues or it could be, could be referring back to the GP or referring for, you know, other, other of, of things.


So I think, I think that is yeah,


it's important to but my experience has been so important not to be too confident that you can


get everyone better given the evidence environment that we live in with exercise is not right.


We could stop the podcast right there and that'd be the that'd be the main lesson.


Don't be overconfident. It's easy to do. You learn a little bit and you try to apply it.


It stops you from being critical. It really ties back to what you were saying earlier in the first episode about


your approach and how you've become so curious about research and about gathering


clinical evidence and measuring lots of things and in many ways being on the frontier of tending empathy practice by trying lots of different things,


having just followed a pattern and I noticed in that summary you just gave then it was interesting.


Use the words may it may be you used suggest.


Can I suggest. Yeah let's see. So it's not I'm not taking a hard line with people and saying you've reached the end of the road here.


You've, you know, this has failed and you're certainly not putting down other clinicians, which is something I respect about you.


There's too much of that. I'm always very mindful, critical hesitance to join in a conversation where, you know,


we're we're talking about how you've been to see a clinician, a doctor or a physio.


And they did nothing for me. And they they gave me some some stretches that didn't work.


You didn't you went there. You don't know what they did in that consultation.


Absolutely. Couldn't agree more. I couldn't agree more. It's really important.


It's really you just don't know. And the same thing the same thing happens with diagnosis because a person's diagnosis one day can be different.


The next day it can be different week to week can be different day to day.


So if she you can even say, oh, this person misdiagnosed you because it could change over time and it often does.


So it's it's it's you do you do learn to be, you know, a little bit careful about judging other people and how they treat.


Do things because it's you just don't you just want that.


That's a, that's a really good point. Mhm. And so it becomes a conversation you know with the patient and,


and you know potentially something that you're going to be a part of the journey rather than


a destination that they've finally got to see you and finally got the right treatment.


Interesting that a lot of the people you've seen have been doing exactly what you would have been prescribing them.


So. So what changes? What do you what do you do differently, do you think,


to get to you do it's fair to say that you get some pretty good clinical outcomes and, you know, expert clinician in this area.


What are some of the things you do differently, do you think, without comparing and contrasting,


how do you take it further and and try to get people better when they have had failed treatment in the past?


Failed treatment is the wrong word. I mean, they haven't yet reached the outcomes that where they need to be.


I think it's. So you've got it's probably comes down to thinking about.


I think comes down and this is where it's going to sound a bit contradictory maybe, but it's now going to be confidence in what you're doing.


So I've just said, don't be too confident now I'm going to completely reverse that.


It's just thinking off my head. I hope this makes sense. But I think what you have to do if you do commit to something like.


All right. So we're going to do this exercise approach. You've got to be confident in the implementation of that approach.


So you've got to you've got to be able to basically roll with the punches.


And there will be times when you think, especially if a difficult tendon in patients.


Am I doing the right thing? Am I actually is this person actually going to get better with this approach?


Is it? Look, they've come back to me a month later. They know better.


What do I do? You know, they've already had a two year history.


Watch what I do now. And you've got to be confident that you've got to stick to the principles and you've got to keep on going.


And that's not to say. Keep on going, regardless of what happens or see it.


Come back in there. You know, they can't walk away. They're much worse.


And obviously, you've got to you've got to be confident because your diagnosis is right and you've got all the other things.


All your ducks are aligned. But if they are, you've got it.


You've got to follow it through. You can't just panic and say when the patient comes in panicking, you can't panic as well.


You can't you can't join that choir of panic because it's just going to lead to


more panic and it's going to lead to them going to get injections and surgery.


So the nature of tuned that up at these a cycle of of overloading and the loading and reaction


to that and the reaction that you have to it is not necessarily helpful for the condition.


It's a condition that takes many months to improve.


So I think the word you said there that was really helpful was commit and then have confidence to what you've committed to and then be aware of those,


you know,


daily fluctuations and the fact that it's not going to be easy and it's going to require a lot of effort versus just confidence with everything.


Well, that will lead to biases and lead you to finding, as you said in the first episode,


finding results that aren't there because you haven't measured accurately.


And I'm so let's let's segway into research.


I think that's a is a good time to talk about some of the research that you do at Monash Uni and previously.


So tell us currently about your. Tell us about your current interests in research at Monash and and your program of research.


So we basically have we basically have a well we call ourselves the muscle skeletal Monash Process Little Research Unit.


We've got, we've got a group of academics and post-docs and students focused on musculoskeletal conditions basically.


But we generally do trials, so as a few trials that I'm working on, but oils, we're also very interested in lab mechanisms work.


So looking at, say, for example, what,


how do people with Achilles from the hop and does that change over time with exercise various various sort of led by studies as well.


So it's it's a real mix of different things.


It's a real mix of difference in telehealth research, but it's all under the banner of tendon empathy, musculoskeletal type conditions, basically.


But it's it's just a fortunate, fortunate, fortunate position that I'm finding myself in.


I don't know how I got here, really. I don't know if that's a good message for for new grads.


But it's I just feel lucky to be able to go to work every day and just think and try and answer questions.


And it's just it's a fortunate it's just a good it's it's a it's a fun it is a fun job.


Definitely shows that message for new grads. It's if you're thinking about research and you've got some interest in research,


it is definitely and I find it a very fulfilling type PowerPoint have gone down for sure.


I feel the same about my work in physio education. You wake up every day, you do have to find your calling.


You've got to find something that that you would do anyway.


You need to put a roof over your family's head, but something that you would do in your spare time if you weren't being paid for it.


And so that is a really important point. So you've got to have physiotherapy or any musculoskeletal practices.


Takes a lot of energy, doesn't it? You can get burned out pretty quick, pretty easily,


and if you can go into it with a lot of energy and keep thinking about why you're doing it, I think that's really important, by the way.


So so for listeners,


Peter and I work together at Monash University and we're both a member of the Monash Musculoskeletal Research Unit and one of our PhD students.


Salim Tavakoli, is doing a really interesting PhD on load measuring load intended allopathy.


So using sensors to measure people's load as they move around every day.


So there's an example of one of the research projects, and I had sent him on the MMR podcast yesterday, so we got it to speak.


It's fantastic. So that'll be coming out, right? So try to look forward, sir, if you're interested.


I was very, very happy to get her talking on the podcast because she's very, very good.


But, you know, no, no one will know if she doesn't turn on the microphone and talk.


And you might read her papers, but it was really good to hear from her.


So I'll put a link to that episode in the show notes.


But if you're interested in more of the just specific research chats, you can follow that episode and other episodes there.


Let's just wrap this up. I know you've got another research meeting, Pete.


So what are some of the key resources that clinicians and students should know about or should know about to learn more about tendon apathy.


So websites and courses, you've got your own course.


For example, there my my course is the most original intent of the course is what else is there?


There's lots of there's lots of online stuff. Go on Twitter.


You know, the stuff that you do on Twitter, the stuff that Tom Google and other people do on Twitter is really good.


There's so much out there now. It's just just be critical, though.


Just be critical. Just always think if someone's got a really strong opinion, have the have they got strong evidence to substantiate that?


And that's that's really important. So testing capacity, just be critical.


Whatever your rating, even my stuff, if I'm saying stuff that doesn't make sense just in moments, I know this is wrong.


And if it is wrong, I'll I'll change it. And I think that's a sign of the person you want to listen to, the person who says, hey,


I don't know, this is my best guess of this would be this is willing to change their mind.


Would you? Evidence comes along and you know that like we're talking about before, that's what makes this profession fun,


is that you're thinking and you've been critical and you're always learning.


That's why we're doing this conversation right now. It's all it's a professional development.


I get to chat to lots of people. That's my goal and hopefully the listeners find these conversations really helpful and we can share


that rather than having corridor conversations that are amazing and no one else gets to hear it.


Well, I think targeting new grads is really good idea because new grads,


I mean, I think back and I've already set about my sort of level of ineptness.


When I was at New Grad, and I'm not saying for a second that everyone's as inept as I was,


but if if they're uncertain, things like this are really useful for them.


And I think it's a good it's a good, good sort of time to be upskilling it and hearing other people, particularly someone who's at the advanced level,


talking about their uncertainty and talking about the importance of not being overconfident,


but then committing to things that they know they need to stay the course on.


I think that's important to know. I would have loved to hear this when I was a new grad, so I hope it's helpful to listeners.


He loves answering questions and he mentioned his course as well, which is really popular.


So let's wrap it up there. Thank you very much, Peter. And listeners, see you in the next episode.

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