https://podcasts.apple.com/us/podcast/jacked-athlete-podcast/id1462537296?i=1000727400660
Jon: “In the UK, if you do sports medicine rather than sports surgery, then tendinopathy is one of the biggest challenges.”
Jon: “My background in rheumatology, I was seeing quite a lot of inflammatory disorders and being asked is this an inflammation issue? Is it a tendon issue?”
Jon: “I think people often just sort of lump things as one thing. They kind of say tendinopathy and just imagine that it’s this one thing that occurs in multiple different tendons without even thinking about which tendon it is and what its function is… We’re seeing these different types of cases and everyone’s kind of lumping the treatment together as one, whether that be a post-menopausal athlete or a kid or someone who is overweight with diabetes and gout… I think we’re recognizing these’re completely different pathologies and need a different approach.”
Jarrod: “Tendinopathy, which if you translate from Latin just means disease of the tendon, it doesn’t really give you a discrete diagnosis.”
Jarrod: “Working with John, I opened my eyes to a little bit of quite a few more diagnoses. So these post-menopausal women’s, these metabolic tendons, these rheumatological tendons.”,
Jon: “When we scan the tendon, there are some people where metabolic disease can drive the problems within the tendon. And what you can sometimes see is areas where you get uric acid crystals that build up and create a tophi, which is a collection of those crystals in the tendon.”
Jon: “We’ve heard of calcific tendinopathy as an acute inflammatory response in the shoulder, but you can see it in the Achilles and the patella and lots of other tendons. And so when we see those sort of soft calcifications or little deposits, we kind of then start going down a slightly different screen in terms of metabolic blood tests, inflammatory blood tests, looking at disorders of calcium metabolism, et cetera, to rule out any other causes of that tendon.”
Jon: “We’ve had some (metabolic tendons) where we’ll stick them onto gout medication to reduce the size of those tophi and big doses of anti-inflammatories rather than necessarily just saying, right, we’re going to load you.”
Jarrod: “When you do load them (metabolic tendons), if you’re too aggressive, they get really sore really quickly. And so those metabolic type tendons, they don’t respond quickly to a good loading strategy because the environment for the tenocytes is not ideal.”
Jarrod: “The tendons are like the litmus test for the human body. If you have gout or diabetes or any kind of HLA-B27 positives, it will manifest in the tendon. And so they don’t respond particularly well to aggressive loading. In fact, they go the opposite way and people get really sore really quickly. So it’s good to differentiate them out, separate them because not all tendons are the same and they need to be treated differently.”
Jon: “Most of the metabolic problems tend to be older patients because it’s things like postmenopause, obesity, thyroid disease, uncontrolled type 2 diabetes, occasionally type 1 diabetes. These tend to be in a slightly older age group. The younger guys, though, are the ones where you should be thinking about, is this an inflammatory disease?”
Jon: “The HLA-B27. In North European Caucasians, about 8 % of us will carry that gene. So in your average sports team, there’ll be one player that carries that gene on average. But if you have that gene, you’re more prone to a number of autoimmune diseases that create inflammation like psoriasis of the skin, ulcerative colitis, Crohn’s, but also inflammatory disease in the spine and some called enthesitis.”
Jon: “If you’ve got a young man, especially because they tend to present more frequently with these particular conditions with significant morning stiffness pain and insertions of both Achilles, then that’s where if they were in our clinic, we’d be asking them about skin issues, looking at their nails, looking at their hair, looking at the belly button for psoriasis, doing some blood tests for inflammatory markers, B27. And potentially those are probably one of the few times that we might consider an MRI scan because we might see some tendon change on the actual insertion. But if it’s a true enthesitis, you often get a big amount of bone marrow edema at the insertion on the calcaneus and that helps us to make that diagnosis as well. Whereas a lot of the time we wouldn’t be using MRI at all.”
Jarrod: “Dr. Paul Kirwan is a really close friend of mine, he came up with a really good acronym called SCREEN’D, which is Skin Colitis Relatives (which is the HLAB27), Eyes, Early morning stiffness, the Nails, Dactylitis and Enthesitis and movement and medication… And that’s really worth looking into for people where you think that it might be one of those, we call them spondyloarthropophies.”
Jon on the inflammatory cases: “We’re much more likely to hit them with longer periods of high dose anti-inflammatories… this would be someone where you’d be looking to continue that anti-inflammatory indefinitely if you’re getting a response. And then those that have more severe disease, in the UK, we’ve got various guidelines, but if their symptoms are bad enough, you use something called biological therapies. So these are essentially working at the very start of the inflammatory cascade. And these drugs have been around about 25 years developed for rheumatoid arthritis, but now have evolved to be used in the spondyloarthropathies and enthesitises.”
Jon on taking NSAIDs: “Some patients do very well with a short course of anti-inflammatory just to dampen down the pain signal to encourage them to be able to load at a higher start point. It’s not like a cure, but it may control symptoms in some and probably the earlier in the disease course, the better its response.”
Jarrod: “If people suffer an acute episode of tendinopathy, they often de-load very, very quickly. And one of the issues with de-loading is very obvious. You lose the stiffness measures that exist within the tendon and you lose muscle mass and strength. And that probably propagates moving on to more of this sub-acute towards chronic phase. Now, I don’t think non-steroidals are particularly good for the chronic tendinopathies. I do think, as Jon said, giving somebody a short course of anti-inflammatories to get them pain-free so they can restart their loading is a really effective way to minimize the chronicity of it and to minimize he effect of the mechanical properties and the effect of ⁓ the atrophy or ⁓ loss of strength. So think there is some need for it. We do use it a lot. We don’t use it for everyone, but we do use it a lot, particularly with those that just can’t load or that are in a lot of pain.”
Jon on NSAID type: “We tend to use the more COX specific NSAIDs… My experience of using anti-inflammatories for my inflammatory patients is that the COX specific anti-inflammatories like Celecoxib, Etoracoxib tend to be very potent anti-inflammatories and they’re kinder on the stomach. You can’t really use them in your older age group if you’ve got a metabolic tendon where there’s a history of heart disease or blood pressure issues but in the younger patient, it’s safer than the standard anti-inflammatories and probably more potent.”
Jon on using NSAIDs: “We normally say to people that the risk of this is pretty low. We’re going to try this just even if you’ve got pain of 5 out of 10, if we can notch that down to 3, then you’re going to be more comfortable loading.”
Jarrod: “One of the most important things is to get a history and you’re not going to learn much if you just look at a scan. And so getting a good clinical history, understanding why they’ve got it, where it came from, gives you clues as to what it might be and how you can reverse it. So we spend a good half an hour talking to the patient about their history.”
Jarrod: “Jon does the grayscale ultrasound and color Doppler because that does give us some insight. If it’s insertional, it’s good to see if there’s any spurs… and we’re looking at things like the anatomy, whether there’s accessory soleus or a very short tendon or is it a parotendinopathy, what the Doppler signal is showing in the patellar tendon, is there fat pad inflammation, if you flex the knee under ultrasound, do they have a plica?… And then I do the UTC because the UTC gives us a lot more information what’s going on within the tendon. So with patellar and Achilles, it’s always nice to see exactly what the diagnosis is.”
Jarrod: “Jon comes from a, from a doctor background. I come from a physio conservative background and people like that. They want to hear both sides of the coin… All tendinopathy should be treated conservatively to start with, and Jon and I are really the gatekeepers of that conservative management plan to start with. And if they fail that, then we have no problem sending them on. And they’ll go and see, you know, depending on the tendinopathy, they’ll go and see a different orthopedic surgeon.”
Jarrod: “That’s really the key for John and I is the diagnosis. If you know what it is, then it’s a lot easier to treat. If you have no idea and you’re throwing darts with your blindfold on, you might get it. You might not. And loading doesn’t, is not always the answer for people. It’s for the vast majority, but not for everyone.”
Jon on intrasubstance tears: “I think the MRI often undercalls or overcalls those because it’s just looking at fluid signal. I think with the UTC, that’s really changed what we see in those athletes. And certainly I think that in the elite sport, those intrasubstance tears are a very common presentation as to why that player can’t play. Whereas you don’t really see so many of those in the non-elite athletes. It’s a much less common diagnosis.”
Jon on plantaris: “I think it’s a lot more common than it’s given credit for… When we first started, I think we looked at our first 100 cases or so. And when we presented it, a few people who worked in tendons were like, whoa, you’re saying like 70 % of these, you think that the plantaris was a factor. And we would often have a patient who might have some plantaris related changes and then some ventral changes as well. So it might have two diagnosed, two areas of the tendon. But I think it’s much more common than we give it credit for.”
Jon on plantaris: “I often will do an injection of a hyaluronic acid, which is like a visco supplement designed mainly for knee, osteoarthritis, but it acts as a lubricant that can settle down that inflammatory reaction in the fat pad between the two tendons to allow Jarrod to then load them properly and he’ll adapt that program if they’ve got a plantaris-related problem.”
Jarrod on plantaris: “There was a huge population study done in the Netherlands that showed that 80 to 85 % of the population have a plantaris tendon. But if you read anatomy texts, it says anywhere between 10 and 15 % of the population have a plantaris tendon.”
Jarrod on plantaris: “The course of travel does some really interesting things, whether it invaginates into the tendon, it attaches to the calcaneus, it slides in on the ventral surface of the calcaneus and wraps around the Achilles.”
Jarrod on plantaris: “We don’t use it anymore. It’s vestigial. It’s not useful. It might’ve been useful when we hung from trees. You have one here [at the forearm], Palmaris longus. We don’t use it. Some of the surgeons use it for grafting if you tear a finger tendon, but it’s not useful.”
Jon on paratendinopathy: “We see a few cases… We often see it as a secondary problem. So you sometimes see it in people who’ve either not run before or they suddenly massively increase their load and they get a raging inflammatory response within that tendon. And those are the ones that get crepitus and just don’t want to walk. It’s really severe and you’ve got to sort of offload them significantly and dampen down that inflammatory response. I think we see it quite a lot secondarily to small areas of either a tear or severe tendinopathy that’s just underneath the paratenon dorsally. And we do see it occasionally post-surgery as a complication when the tendons just reacted and that whole area reacts. The true paratendinopathies that are bilateral and severe are relatively unusual. Maybe one or two a year or less than 1 % of the cases we see probably.”
Jarrod on paratendinopathy: “They’ll usually be stopped by their GP or hopefully their physiotherapist, a little bit of crepitus in the tendon, give them some anti-inflammatories or a topical anti-inflammatory patch, reduce their load and then reload them and they seem to settle quite quickly.”
Jarrod on Haglund’s Deformity: “It’s trying to manage them conservatively as long as they can. And if they can’t, then they have surgery. If they can, great. They do their loading, then you load them out of that painful area, then you gradually increase it or introduce those end range dorsiflexion positions. And hopefully they get on their merry way. If they don’t, then we send them off to our surgeons.”
Jon: “We see calcification quite commonly, especially in the more middle aged to older age group where the tendons have gone through a long cycle of disrepair and the calcification can be a normal response to that… And often when we scan them, the changes are bilateral, but one side hurts, the other one doesn’t.”
Jon on calcifications: “We see quite a lot of it in the proximal patellar tendon, definitely. And again, you’re kind of talking about the Haglunds and that compression tendinopathy. Some of the patellar tendons that we’re starting to see more and more of, we’re starting to look at patellar shape and whether that inferior pole of the patella is more beat and it has a similar compressive effect on certain activities.”
Jarrod on big, painful calcifications: “If you leave that in there, they’re not going to get better because if you have a tensile spring and you put something that’s non-elastic in the middle of it, it’s going to be sore and it’s going to be really, really aggravated with any kind of decelerating or landing from a jump. They just don’t tolerate it.”
Jon: “I believe that shockwave’s primary effect is probably on those baby little nerve endings that are growing into the tendon rather than necessarily breaking up the calcification or remodeling the tendon cells. So if it helps the pain and the pain is lower, so you can load them more, then that’s a good thing.”
Jarrod on shockwave: “I think it’s really good for plantar fascia. I think it’s really good for proximal hamstring and potentially quad tendon but I don’t think it works particularly well at the patella tendon. I think it’s quite painful. A lot of patients really don’t like it… I’m not sure it really changes structure. I think it just changes the afferent nerve endings and people, it modulates pain a bit better for them.”
Jon: “We know that the blood supply to the tendon is not great. So it comes through the fat pads and the soft tissue superficially, which are much more highly innervated or through the paratenon.”
Jarrod: “Jon and I were coming up against these difficult patellar tendons that weren’t getting better. And we were watching the surgeons basically cut open the tendon through the really good parts of the tendon and peel it open and then just pluck out [bad tissue]… and we’d see on the grayscale ultrasound three months or six months, you’d still see tendinopathy and you’d still see calcifications because they can’t see them [without ultrasound during surgery]. So I sort of approached Sam Church and said, Hey, Sam, what do you think about this? Why would you be interested in trying an ultrasound guided? Because under ultrasound, you can see everything. We can keep an eye on the size of the tendon, make sure we don’t do too much. I can position you really well. And he said, all right, let’s give it a go.”
Jarrod: “Not all patellar tendinopathy is caused primarily from the patellar tendon. Some of it is secondary to patella alta, which is where the patella sits quite high. And they’re quite prone to tendinopathy because it’s really the patellar sesamoid and it’s the lever arms that are essentially camming up against it. And so you put a lot more stress on the underneath side of the tendon. And those don’t really respond to anything other than doing a TTO, which is a tibial tubercle osteotomy, which is just dropping the insertion down. It’s a fancy way of doing it, but it brings the patella down into the, down into the trochlear. And those patients do really, really well.”
Jarrod: “The Blackburn Peel Index or BPI… We set a marker of about 1.2. So above 1.2, we’ll do a TTO. Below 1.2, we’ll try conservative first. And Jon and I have seen, one particular young kid who was a 1.6 BPI… I mean, his kneecap was halfway up his thigh and he’s never going to respond to loading. He’s never going to respond to just doing an arthroscopic ultrasound guided debridement because his kneecap is so high, we can’t actually get to it.”
Jarrod: “The analogy that I give to people is a normal healthy tendon is parallel, intact and aligned really healthy. When we shine the scope light on it, it looks like, the reflective cycling jacket, but white. So you’re shining tight down and it bounces back, it’s very reflective. Tendinopathy or tendinopathic tendon looks like cotton wool. So it’s all frayed, it’s all sort of disorganized and that’s the fibrillar nature of the tendon and that’s not helpful.”
Jarrod on their patellar tendon operation: “We can get people back really quickly. And so we’ve got a really good cohort that we’ve done it on over 50 patients… And we were able to get patients back anywhere between 12 and 14, sometimes 16 weeks back to sport. So super quick. And while preserving as much of the normal tendon. So it’s a useful procedure.”
Jarrod on partial patellar tendon surgery: “Traditionally, that’s what’s done. They split open the tendon and then try and pluck it out. And the ones that I have seen rehab, they can take up to six to nine months to get back. And it’s a long, time.”
Jarrod: “What I often say to people is if you do have patellar tendinopathy and you do have a tear and loading doesn’t work, please don’t go and get an injection. Please don’t get corticosteroids in the fat pad. Please don’t go and get a PRP because I don’t think, and the evidence is pretty clear, I don’t think it works. You know, biologics for a tear in the patellar tendon. And I say this to other consultants, please come into surgery and have a look. Because once you see that there’s a gap in the tendon, you begin to understand, well, how’s a biologic going to bring that gap together? It’s kind of not. And so, but what we do see is the tendon is in not really good condition. If I’ve had corticosteroid injection or lots of injections into it, they do take longer to heal.”
Jarrod: “The loading rates in the patellar tendon are a lot less than the achilles. If you have that same hole in the achilles, they’re struggling. You you can’t get away in the achilles because, you know, from, from Karen Sibbenagel’s work, the loading rates can be up to 56 to 58 times body weights a second. If they have a hole through the middle of their Achilles, they’re going to feel it, particularly at a high level sport. Whereas in the patellar tendon, because the loading rates are a lot lower, they can kind of get away with abnormal tendon structure. But with some of those cases, yeah, they really do struggle. And if you leave that hole in the patellar tendon and they’re very physically active or they’re an elite athlete, they probably won’t get back or they will always have symptoms.”
Jarrod: “What’s important to notice in tendinopathy, whether it be patella or Achilles, is that it’s a performance affecting disease. So what happens is they become less athletic or they change how they play the game. And if they’re a football player, they might use shortcuts to get to places and they become less athletic… Some of the people that do suffer tendinopathy, they might lose 10, 15, 20 % of their speed. And that might be what makes them a great athlete. And so they lose that. Same with the patellar tendon, they can’t decelerate and cut as quickly as they probably used to. And so they might pick up a different strategy, which is they follow the game a little bit better, but they might lose their athleticism.”
Jon: “Patients do an MRI scan in acute phase and they say, there’s fat pad inflammation as well. And essentially the MRI is just picking up fluid. So a lot of that is this massive new blood vessels feeding into the tendon rather than it being a fat pad inflammation. And if you put a steroid in there, they feel great for four weeks, but surprise, surprise, the pain comes back.”
Jon: “We try to discourage people from putting steroids close to tendons, especially weight bearing tendons, because we have seen, unfortunately, some high level athletes and dancers who then have gone on to rupture… I think that it’s a recipe for disaster if you’ve got an intrasubstance tear and you’re putting steroid anywhere close to that.”
Jarrod: “There is some good evidence to talk about the use of growth hormone in tendinopathy… BPC157 is just a surrogate of growth hormone. It’s just a peptide… it’s kind of like putting a drop of Coca-Cola in a glass and filling it with water and saying it tastes like coke. If you’re going to do BPC157, then you may as well do growth hormone.”
Jon on stem cells: “Some of these things may have an effect. I think that at the moment though, it’s an incredibly expensive way to try and solve a problem. And I think there’s a potential cognitive bias there also where if you’re paying 30K for something, you’re gonna expect that that’s gonna work well.”
Jarrod on stem cells: “My view really is what is a stem cell, it’s an undifferentiated cell. And I think we are not at a place in medicine and science where we can code an undifferentiated cell to become a tenocyte or a chondrocyte or what we want it to be. And simply by saying, well, we’re going to take out some stem cells and put them into the tendon and because it’s in the same location, it’s going to become a tenocyte is very naive.”
Jarrod: “Jon and I sat down many years ago and said, what is conservative for us? And we both agreed that they have to have tried some loading because I think somewhere between probably 70 to 80% of people respond really well to a good loading program… But what is that? It has to be heavy. It has to be three times a week. It has to be progressive. And if they failed that, and they’ve done 8-12 weeks of it, and they haven’t noticed an improvement in their symptoms, then we could talk about something, whether it be, maybe shockwave or some oral medication, or if they’re really in a lot of pain, we take them into theater and we do the procedure I talked about.”
Jarrod: “There are those that have plantaris related [Achilles pain] that come in, they’re really sore. I can see it under grayscale [ultrasound] and UTC. And we offer them oral medication or an HA [hyaluronic acid] injection between plantaris and Achilles. And that gives them a lot of relief.”
Jon: “A lot of the adjuncts we use are often to enable them to load or to enhance that journey. Every single person that comes through gets a loading program, every single one. It’s almost unheard of for us to not have some sort of loading in there.”
Jarrod: “If I could go back, I probably would have a better understanding of things that are not mechanical…. There are so many patients that we see that there is a metabolic issue or they have gout… I think there’s probably a few patients early on in my career where they would have definitely responded and gotten a lot better with a broader approach to managing tendinopathy, from not just a mechanical approach, a loading perspective.”
Jon: “If you’re not winning, you need help. And I think sometimes, from any sort of healthcare provider (physio, S &C, docs, surgeons), is that you feel like, if I’ve got to say to this patient, you need to see someone else, then I failed and they won’t respect me for what I’ve done, but it’s not that at all. It’s completely in their best interest. If you’re not winning, you’ve got to involve someone else.”
Jon: “If there was one way to treat it, everyone would be doing the same thing and we’d all agree. The fact that there’s disagreement means it’s a much more complex problem than we give it credit for. And therefore, we have to keep pushing forward in trying to understand and individualize each patient in front of us and that individual tendon.”
Jon’s Bio: https://www.fortiusclinic.com/specialists/dr-jon-houghton
Jarrod’s Bio: https://www.fortiusclinic.com/specialists/mr-jarrod-antflick
Jon on Instagram: https://www.instagram.com/joffsyboy_2.0/
Jarrod on Instagram: https://www.instagram.com/jla_888/
