Notes
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.”
Jake (09:07)
When we get to some of those metabolic things, I had a ⁓ phone call with a guy yesterday, insertional Achilles bilateral, but he’s young, he was like 24 and just sounded like his wasn’t responding well to loading. How are you guys arriving at this thought that it is a metabolic influence? Is it people that are older? Is it people that you know have metabolic diseases or what type of things are helping you figure this out?
Jon (09:35)
Yeah, so most the metabolic problems tend to be older patients because it’s the sort of things like postmenopause, obesity, thyroid disease, ⁓ uncontrolled type 2 diabetes, occasionally type 1 diabetes. tend to be slightly older age group. The younger guys, though, are the ones where you should be thinking about, this an inflammatory disease? Because
There’s a gene that Jared mentioned called the HLA-B27. Now in North European Caucasians, it’s about 8 % of us will carry that gene. So, you know, in your average sports team, you know, soccer 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 emphyseitis. So, you know, you’ll have heard obviously of the emphasis and how that insertion can be painful. 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, you know, 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
a big amount of bone marrow edema at the incision 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 (11:32)
If you guys feel listeners, think Paul Cohen, a Dr. Paul Cohen is a really close friend of mine, came up with a really good acronym called screened SCREND, which is skin colitis relatives, which is the HLAB27, eyes, early morning stiffness, the nails, dactylitis and entocytosis and movement and medication. And it’s a really good acronym for, I think it’s screened them before you
treat them or something like that, ⁓ which is great, very, very clever. And that’s really worth looking into for people that are where you think that it might be, you know, one of those, we call them spondyloarthropophies.
Jake (12:15)
When it comes to treatment for that, is the treatment isn’t going to be ⁓ loading like it is for any other tendinopathy. It’s going to be trying to manage this inflammation.
Jon (12:28)
Yeah, so we’re much more likely to hit them with longer periods of high dose anti-inflammatories. Now you probably saw in the clinic that we sometimes use anti-inflammatories anyway in an initial phase if it’s, you if they’ve got significant morning stiffness. But 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, you know, 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 emphysoids. So it’s part of that screening process and a different medical management, but there would be some loading.
included also, but as Jarrod said, you can’t push those ones quite as quickly because there’s you know, that environment for the tendon is not controlled at that point in time because it’s very inflammatory.
Jake (13:40)
The okay, this was in my notes. I did catch you guys recommending the NSAIDs for a lot of people and Was it Jill Cook back that sentiment that there’s the tendon pain is not inflammatory But then it told people like no NSAIDs aren’t gonna do anything Yeah, where do you guys stand with this? Why are you guys prescribing NSAIDs for people?
Jon (14:05)
Yeah, so I think that I understand that, but there, you know, there has been a little bit of a counter argument. Jera might talk about that a little bit that potentially in the early stages, there is an inflammatory process, like a lot of injuries where, you know, you roll your ankle, you get a muscle tear, there’s an acute inflammatory response. And then, you know, over time, there’s a repair and a more remodeling phase. And it may be similar in tendons, but we’ve certainly had enough patients where
If they’ve got high levels of pain with significant morning stiffness, we were chatting earlier about the parotinol, which is highly innovative, can be inflammatory. And some of those 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 (15:04)
Yeah, I think one of the interesting things, and I speak to my supervisor who is Professor Peter Magnuson is that 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. do think, as John 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 the mechanical, the 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.
Jake (16:13)
What is the kind of ⁓ anti-inflammatory you guys are giving out?
Jon (16:18)
Yes, we tend to use the more COX specific NSAIDs. There was a called Fallon who wrote a paper on this called the triple therapy in 2008, where they used ibuprofen, which is a pretty standard over the counter anti-inflammatory in the UK, alongside doxycycline, which is actually an antibiotic, but it’s used for kind of long term skin inflammation conditions as well. And it’s got some various properties in anti-TNF, which is one of the
the big chemokines that create inflammation that those biologics were working against that I was talking about earlier. 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.
Jake (17:27)
What are the, are people feeling pretty good once they start this short term course of ⁓ anti-inflammatories?
Jon (17:37)
Yeah, I think we get a real mixed response. There are some that say it did nothing. ⁓ And there are others that have a significant improvement. And they’re sort of like, like really worried about stopping them. ⁓ And again, that helps you form your diagnosis of what might be causing inflammation here, because the ones that respond really well, should we be thinking about other things.
But yeah, I think we normally sort of 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 five out of 10, if we can notch that down to three, then you’re going to be more comfortable loading. Some people are anxious about loading the tendon heavy to start with because they’ve got pain. So I think that some do really well, others no response whatsoever. But you’ve not lost a great deal because we often might only use it for a couple of weeks.
Jake (18:31)
So when you guys get to the, you said earlier that you lump everything, tendinopathy, and they just get lumped in of like, okay, you’re, well like Achilles tendon, your Achilles tendon hurts, okay, Achilles tendinopathy, Alfredson protocol, maybe back in the day they’d give you out. But when I came to see you guys, you start with a conversation with the person, then you go to do some scans. ⁓ Yeah, how important is, I mean, how did you guys arrive at this system of like having the conversation?
of where the pain is, their story, how it came about, doing an ultrasound scan, doing a color doff, or doing UTC scan. ⁓ Is this something you’ve always done to arrive at what you think the diagnosis is, or has it been like trial and error?
Jarrod (19:17)
I think, you know, we’re clinicians. So 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. So for John and I, we’re clinicians, we see patients. ⁓ 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. think that’s really important, whether there’s any familial history, all the things that we’ve just spoken about regarding if there’s any metabolic or any family history, anything like that. Gout is very common and there’s a familial trait. There’s a genetic familial ⁓ trait that you inherit from your father. so sometimes your mother, but mostly your father. that’s really, you need to know that. And then ⁓
You know, John does the ultrasound, grayscale ultrasound and color Doppler because that does give us some insight. If it’s, know, insertional, it’s good to see if there’s any spurs, ⁓ you know, and we’re looking at things like the anatomy, whether there’s accessory soleus or a very short tendon or, you know, is it a parotenonopathy, what the Doppler signal is showing in the patellar tendon, very similar things. ⁓ Is there fat party rotation? You know, if you flex the knee under ultrasound, they, do they have a placard? Can you see the placard?
With the patellar tendon ones, quite often they come from our orthopedic surgeons and they’ve already had an MRI. So that’s really interesting to see are there other changes of their bone edema? Have they got any spurs or any any baked inferior patella pole or any calcifications? Any fat pad irritation? Have the fat pad lit up on T2 weighted MRI? 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. And sometimes it confirms. Sometimes John will do a grayscale ultrasound and say, not really sure. Let’s have a look at the UTC. And then UTC comes up and we can see exactly where some of the changes are. then following that, we put a plan together. And patients like that, know, John comes from a, from a doctor background. I come from a physio conservative background and people like that. They want to, they want to hear both sides of the coin. mean,
John and I don’t really differ that much on things after working together for nine years. It’s not very often we differ. I can sort of say what he’s about to say and vice versa. So, you know, we have a pretty successful clinic. have patients, you know, we have a great pathway because we were sort of the starting point. And when they don’t get better, we send them off to our surgeons for, you know, different operations. So, but I think
all tendinopathy should be treated conservatively to start with, of course, know, ruptures, but they don’t really count as tendinopathy. And, you know, John 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.
Very first summer,
Jon (22:36)
Yeah, very much so. I after nine years, the pattern and the structure has evolved a little bit and things change a little bit from time to time. But I think we kind of settled on something that works for us. And I think it works for the patients. And absolutely, I think, you know, it’s, I’ve always enjoyed working in a team and working with other people. And I think that, you know, there are plenty of cases where
we might have slightly differing views on it. And that’s helpful to discuss there and then. And you’re kind of getting your two for one really, rather than just being with a physical therapist or a sports therapist for a period of time. Then you go see an orthopedic surgeon, they send you for an MRI, they go surgery or not surgery, then they send you back. It’s not so well joined up. We’re case managing these people from diagnosis all the way through. And if they do need
surgical input, we’ve got our colleagues and then Jared will pick up the post-op rehab and manage that. And if there’s a post-op complication, then I might get involved in those things. you know, it’s a structure that works well and we’ve got, you know, we’ve started to develop a great team of surgeons around us also that want to work in that team environment as well. Cause not, not everybody does, doesn’t suit everybody, but I think that it,
You know, certainly for our league sport, we’re just about to launch like an elite tendon unit, which is, you know, myself and Jared and a handful of surgeons, maybe five or six surgeons for the, for the knee and the ankle, where we can do the start to finish in elite sport from diagnosis all the way back to return to play and help that club or that athlete do that, which, you know, for me, that’s, that’s what it should be about. And I’ve always as a physician.
and a rheumatologist, often end up case managing because you’re the kind of, you know, you’ve got a broad spectrum of experience and you bring in the various people that are specialists in those areas to help the pathway.
Jarrod (24:43)
Mm-hmm.
Jake (24:44)
If we go to the Achilles, you guys get referred a lot of people come see you. ⁓ Is it common that you’re seeing someone with Achilles that’s like misdiagnosed or they just completely missed something? And like, are what are these things ⁓ when it comes to Achilles?
Jarrod (25:03)
Yeah, I mean, I would, if I can just chime in, Jay, and then you have a go. You know, a great example was a football player that was, saw our orthopedic surgeon, James Calder, Professor James Calder, was sent to me. I was away in the U.S. He got a, I was away for a couple of weeks. He then went and saw somebody else. And by the end of the story, he’d done six months and he’d come back full circle and he’d had an osteotragonum removed. He’d had a
gastroc lengthening, a plantarosectomy and a failed Haglund’s resection. For different surgeries, for something that sounded like, I’m not sure if it sounded like, he had a plantarose related medial mid-portion achilles xenonopathy. So his plantarose was close to the adhere, is what it sounded like. So we often do get people that come in that have been around the houses and it’s just the time. mean, John and I see a huge volume.
of patients. You probably see over a thousand patients a year and that’s quite a lot of Achilles and patellar tendons. So we see a lot of them. We’ve got great imaging. We’ve got great surgeons. We get great input from different people. We have fantastic radiologists, some of the best radiologists in the world. ⁓ And we’re fortunate because we like to think that we can try and get people back to sport. But to do that, you need to know what the diagnosis is.
And that’s really the key is for John and I is the diagnosis. If you know what it is, then it’s pretty, it’s a lot easier to treat if you know what it is. If you have no idea and you’re, you know, throwing darts with your blindfold on you, 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 (26:51)
Yeah, I think I’d echo that. guess, you know, listen, everybody’s doing their best on the whole. It’s pretty unusual for us to kind of go, this is completely wrong. But we definitely have patients where we’re the third or fourth opinion and people have tried a few things, throwing this at it, throwing that at it. I think though, that’s where…
Certainly for me, the UTC has been super helpful and especially in elite sport, know, a lot of the time, as soon as you get a player coming in who says, I’ve had Achilles problems every pre-season and every Christmas when the load is high for seven years and I just can’t shake it, then the first thing we’re doing is let’s look for the big clan tyrants that’s just causing that friction when you’re in periods of high load.
So I think that, from my perspective, yeah, those are the things that we often see. And probably the other thing in elite sport that is definitely being changed with the UTC is the intrasubstance tears. And again, I think the MRI is not, it often undercalls or overcalls those depending, because it’s just looking at fluid signal. I think with the UTC, that’s really, really changed what
we see in those athletes. And certainly I think that in that particular cohort, 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.
Jake (28:36)
How common? I know last time we talked about the planterus. ⁓ How common is that?
Jarrod (28:43)
think we probably see every clinic maybe two or three, maybe three or four, something like that.
Jon (28:52)
Yeah, I think it’s a lot more common than it’s given credit for. ⁓ And certainly, think when we first started, I think we looked at our first like 100 cases or so. And when we presented it, a few people who worked in tenants were like, whoa, you’re saying like 70 % of these, you think that the plantarist was a factor. And we would often have a patient who might have some plantarist 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. I think that there are some really good treatments from how Jared changes the loading for that patient. I often will do an injection of a hyaluronic acid, which is like a visco supplement designed mainly for knee, osteoarthritis, but it’s a…
you know, acts as a lubricant can settle down that inflammatory reaction in the fat pod between the two tendons to allow Jarrod to then load them properly and he’ll adapt that program if they’ve got a plantarys-related problem.
Jake (30:02)
What about… ⁓
Jarrod (30:04)
I was going to say, sorry. think in the US it’s not so well commonly thought of as a diagnosis, but we do need to keep in mind 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. when you…
think that only 15 % of the population have one, it’s already a diagnosis that you’re not interested in or that you wouldn’t think of. So actually a lot of people, most people have a plantaris tendon, it just changes its shape or it might be extremely small or it might be extremely large. And there was a good paper that John and I were involved in at Imperial with one of the PhD looking at the different location.
of plantarist, the course of travel. And it 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. So I think we do see a lot of them. We do see some interesting ones, we do see some really big ones. And then we see some that it’s not a factor. They don’t have a plantarist tendon, but it’s something that we do like to keep an eye on, particularly in the elites, as John said, where we’ve had, I mean, one
Jon (31:14)
.
Jarrod (31:21)
particular patient who I’ll never forget. think he had a 40 year history of medial Achilles pain. And I think you might remember who I’m talking about, John, the Italian fellow. And he, you know, it was so, so obvious what his problem was. And we took his plantarys out and we didn’t, but James Calder did. And, you know, changed his life because he could run, he could play football, he could do all the things that he just couldn’t do. yeah.
Jake (31:51)
What is the point of it in the human body?
Jarrod (31:54)
Vestigial,
we don’t use it anymore. No, we don’t use it. It’s vestigial. It’s not useful. It might’ve been useful when we hung from trees. You have one here, 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. The muscle’s too small to have.
Jon (32:14)
Yeah, we always explain to patients by just saying, you know, we used to use it more when we hung upside down in trees. And that’s the way we’d explain it the basic way. But no, it serves no purpose now.
Jake (32:27)
was listening to another interview Jared, have you had a plight terrorist related pain in the past?
Jarrod (32:33)
I have personally, yeah. I have, yeah. Let’s start my run. ⁓ I’m not a massive runner. I was running a little bit. What did I do? I just kind of went back to doing some exercises and yeah, it it settles. But I know that if I went now and did a, you know, a 10 mile run, I would be very sore along, just my right achilles, I’d be very sore along that medial column. So.
Jake (32:37)
what did you do for it?
Yeah. The other one, the parateninopathy. ⁓ Yeah, I was telling Jared earlier that I was talking to a guy who sounded like that’s what he had. The only thing that helped his Achilles was complete rest, like completely shutting it down, then he could get back to it. How often are you guys seeing this, ⁓ the parateninopathy? ⁓
Jarrod (33:00)
Not related.
Jon (33:25)
think we see a few cases. think what I would say is that 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 shape. And those are the ones that get like crepitus and like just don’t want to walk. It’s really severe and you’ve got to sort of offload them significantly.
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 parotene on dorsally. And we do see it occasionally ⁓ post-surgery as a complication, you know, when the tendons just reacted and that whole area reacts. So, you know, the true ⁓ parotendinopathies that are
bi-lateral severe are relatively unusual. Maybe one or two a year or less than 1 % of the cases we see probably.
Jake (34:34)
Yeah, Jared, your experience with the peritonopathy?
Jarrod (34:37)
I mean, I would echo what John said. It’s unusual to get just in isolation and we don’t see lots of them, a parotenonopathy, but we see a lot of them post-surgically, because you’ve obviously cut open the tendon and then all the surgeons will sew back very carefully the parotenon because it’s very necessary and they do get some irritation to it. I mean, we don’t really see just…
I’ve just got a paratenanopathy. They’ll usually be stopped by their GP or hopefully their physiotherapist, a little bit of creposis 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. But I think John and I have the unenviable task of being the second or third opinion. And I was saying to John a little while ago, we don’t get to see people that have had tenanopathy for a week or two.
you know, they’re always sprained out by their GPs or their physiotherapists. We see the ones that are really struggling that have really bad patellar tendon or Achilles tendinopathy. And, you know, they’ve come to a point where they’re just fed up. So we don’t see very, very acute ones. I just, you know, have Achilles problems last week and what do I do?
Jake (35:54)
Where do you guys stand with the Hagelins deformity? And if someone has that long standing pain, are the options there?
Jon (36:03)
Do you want to take this one, Jay?
Jarrod (36:05)
⁓ Yeah, I mean, listen, it’s a mechanical ⁓ camming effect that it has on the tendon. I think there are some that can manage conservatively and you can load them, but you just don’t load them to end range door sufflection. And there’s, you know, who I’m about to say in Copenhagen that published a really interesting paper about, you know, taking them out of compression. was sort of a great theory put by Jill Cook.
which holds true, it’s 100 % accurate, but he actually proved it. I’m just trying to think of his name.
Jake (36:38)
Pringles, Lauren Pringles.
Jarrod (36:40)
Lauren Pringles, fantastic paper. He’s done some really good work. And I think if you do have a true haggling, it can be a problem. And we see haggling where you get a ventral surface tear, where the tendon is actually butting up against the haggling and they’ll get a tear. depending where the tendon insertion is, sorry, where the tendonopathy is, if it’s, you know,
just off the calcaneal shelf, so proximal, a little bit further off the heel bone, then we can do them minimally invasively. And so we’ve done quite a few of them under ultrasound guidance where the surgeons will come in and they’ll take away the Haglunds with a burr. And we use thoroscopy for that. So it’s an X-ray machine that comes into theater and they just keep on taking images to make sure that the Haglunds has been resected. I also use the ultrasound to make sure that it’s smoothed off a little bit. And then we…
we’ve just used two little holes meeting the lateral gutter of the Achilles, then they just take out the scope and an incisor and put it back up and we try and clear out the ventral surface of the tendon under arthroscopy. So really all they’re left with is just two little holes rather than a big incision over the back. But if you have a haggling, you always try and manage it conservatively. Some of the imaging is important. So if they have lots of bone edema, they have a spur,
you’re going to really struggle to manage that. Particularly if they have a spill, you’re going to struggle to manage that conservatively. And so we like to look at MR and x-ray for that because you can’t always see it under ultrasound. And then it’s trying to manage the 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 dorsal flexion positions. And hopefully they get on their merry way. If they don’t, then we send them off to our surgeons.
Jake (38:35)
What with the Achilles, you guys see in calcifications and what is the, how does that change anything? ⁓ And then off the back of that shockwave, is this something you guys ever are using?
Jon (38:48)
Yeah, I think we see calcification quite commonly, especially in the, you know, the more middle aged to older age group where the tendons gone through a long cycle of disrepair and the calcification can be a normal response to that. And in some people it could really aggravate the tendon. In others you may see like a bone spur. So rather than, yes, it is calcification, but it’s a spur that’s actually attached to the calcaneers. And often
when we scan them, the changes are bilateral, but one side hurts, the other one doesn’t. So I think that it’s useful from an educational point of view for people to kind of see that, but also just to say, look, you’ve got this piece of calcification, it changes how the tendon moves and works, and it can irritate the tendon because it’s not a natural shape of attachment that a normal attachment is, which, you know, that’s
it’s designed that way so that it can shield some of those stresses. But when you get a big spur or a calcification in the wrong part of the tendon, you can’t shield it from those stresses. I think that we see it pretty commonly. ⁓ 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. So yeah, common.
Jarrod (40:22)
We, I just spent the last five hours in theater and we just yanked out a 12 millimeter calcification out of the patella tendon. And I mean, he was in significant amounts of pain and I do the pre-op outcome measures and you know, he could barely lunge, he could barely single leg squat. And he had this enormous calcification sitting just on that lateral proximal edge of the, of the patella tendon. And 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 what’s the highest load in the patella tendon is probably decelerating or landing from a jump. They just don’t tolerate it. we just, you know, it’s important depending on where it is, we usually do take them out.
Jake (41:13)
Shockwave, is there any potential to get it out with Shockwave or no?
Jon (41:20)
think it’s unlikely to get it out unless it’s relatively acute. So shockwave may change that acute one, it’s not going to change a bone spur or a really chronic one. However, I, you know, I don’t use a lot of shockwave now. ⁓ But that’s probably, you know, because we kind of do in the joint clinic, we’re seeing the higher end cases and, know, they’re much more available in the UK now than it used to be. So you don’t need a doctor to do it. Lots of physios.
trialed this already and they’ll either have helped or not helped. I think though that in those cases, that’s where I would say it’s worth doing that. But 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 (42:24)
No, I agree. I agree. I find it just if you asked where do I find it effective, I think it’s really good for plantar fascia. I think it’s really good for proximal hamstring and potentially quad tendon. I seem to get good results, 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. And in the Achilles, don’t use it occasionally at the insertion, but I don’t.
I it really works and I use focus, not radial. So it’s not as painful. not like a jackhammer, but I would agree with John. I’m not sure it really changes structure. think it just changes the afferent nerve endings and people, it modulates pain a bit better for them.
Jake (43:04)
Yeah. OK, so what are you guys seeing with you have the color Doppler and maybe this thought on like the neo innervation in the tendon? ⁓ Yeah, what do you what’s the process of all this happening? Does someone have a tendinopathy and then we get innervation in the tendon, more blood flow or what exactly is going on? Is this this a normal, good adaptive response or do you look at this as a bad response?
Jon (43:32)
I think it can help you in a diagnosis sometimes. Certainly when our ultrasound images weren’t quite as good as they are today, but you could see a little bit of Doppler, then you could say, it’s a slightly thick tendon, increased Doppler. If you see tendons very early, you rarely see this even in the acute injuries because it is much more of a failed adaptive response. We start often to start seeing those near vessels at maybe three months post
pain or four months post pain. And certainly it does appear that you’ve got a normal response to pain or an injury, the tendon saying, I’m struggling, come heal me, you get an in growth of vessels with baby little nerve endings on those. then you get into this cycle sometimes and then the tendon cell secreting substance is like substance P, but just really don’t get on with
small, friable nerves ⁓ and you get into that cycle. think it’s, I wouldn’t use it necessarily as saying that we’re having a good treatment response because the Doppler flow is less today. I think it’s very difficult to quantify that. If you go from raging to nothing, that’s a really good sign, but saying, it’s severe to moderate, therefore we’re winning.
I don’t think that you can be that accurate with it because it will change day to day on a number of factors. And I think that’s where the UTC is much more reproducible, much more consistent in terms of structure.
Jake (45:11)
With, okay, these, this blood flow nerve ending, is this coming from the fat pads? Sorry if I just haven’t come across it yet or what’s going on with the fat pad? there, what’s the involvement with that in attendance?
Jon (45:26)
Yeah, so with a fat pad, those are highly innovative, more rich blood supply. Often the blood supply within the tendon itself is much more limited. So often you will see, for example, if we look at the knee, ⁓ one of the key things that we’re thinking, if it’s a potential surgical case, and I think Jared spoke through this with you when you were here with us, is if you’ve got blood vessels feeding up from the deep fat pad,
We also look at the superficial part of the tendon and if we’re seeing significant near vessels coming superficially, then that’s something that you need to deal with at surgery with a kind of little mini scrape that Jared will tell you some more about. But I think, yes, 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 parathenum.
Jake (46:25)
Yeah, Jared, so what is this scrape?
Jarrod (46:32)
So it’s something that Hock and Alfredson kind of made very famous. They did hundreds and hundreds of cases with Lorenzo Maschi and then Hockan retired and I brought it. watched them do it quite a few times some years ago and I sort of, John 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 and through the really good parts of the tendon and peel it open and then just pluck out, you know, and we’d see on the grayscale ultrasound.
three months or six months, you’d still see tennantopathy and you’d still see calcifications because they can’t see them. 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. So
We sort of have a bit of a criteria. It’s even more imaging, unfortunately, but we, and I was smiling earlier when we were talking about learning new things. And one of the things that John and I kind of sort of learned was that not all patellar tendon or not all patellar tendinopathy are caused primarily from the patellar tendon. So some of it is secondary to have been patellar alter, which is where the patellar sits quite high. And they’re quite prone to tendinopathy because it’s really the patellar sessimoid and
It’s the lever arms are essentially it’s 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 tubular tube called 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. And so we do a combined where we clean up the back of the tendon, maybe do a bit of a scrape and then Mr. Anand, who I work with,
He will then do a TTO and pull it back down and they do fantastically well. mean, they, we’ve had quite a few of them and they just don’t have pain. But in essence, the scrape, it was, if they’re, if they’re not patellar alter, and we determine that with what’s called the Blackburn Peel Index or BPI. And we sort of set a marker of about 1.2. So above 1.2, we’ll do a TTO below 1.2. We’ll try a conservative first. And John and I have seen, we’ve seen a couple of cases that one particular young kid who was
I 1.6 BPI, something, 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 one because his kneecap is so high, we can’t actually get to it. So the ultrasound guided debridement is actually that, know, Mr. Anand, his name’s Sanjay, he does a medial and lateral port and he’ll sort of clear up a bit of the fat pad and then I will under sterile conditions,
⁓ aseptic. So we both scrub in and I will put an ultrasound probe that’s covered with, ⁓ Ola sterile gel. And I guide him to where the tendinopathy is, whether it be calcification, whether it be a tear and we clean up the tendon. And the analogy that I give to people is a normal healthy tendon is parallel, intact and aligned really healthy. It looks like when we shine the scope light on it, it looks like, ⁓ the reflective cycling jacket, but white.
So you’re trying to lie down on it, bounces back, it’s very reflective. Tendonopathy 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. So we derive that back to normal healthy tendon and we then take the scope out and we do a little mini incision and we scrape the fat pad. We have another fat pad, but the subcutaneous bursar sometimes gets quite adhered.
and the tendon can get quite thick and we scrape that back and then we sew them up and off they go and they start their physio quite quickly. And so the beauty of that procedure is that 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. I think we’re about 52 or 53 now, soon to be close to 60 by the end of next week. 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. We do a similar one in the Achilles tendon with the hadons resection, just depending on where the tendon attaches. yeah, mean, the goal of it all is to keep it minimally invasive. So preserve as much normal healthy tendon as we can, try and make a smaller incision as possible.
and try and get patients moving and walking and loading the tendon as quickly as we can.
Jake (51:27)
I had a way back when I was in college, a partial patellar tendon tear they suspected. So I got surgery and I don’t even remember what they did, but I’m pretty sure it was like that big cut. And I was ⁓ in a brace straight leg for a month. ⁓ So like doing straight leg raises was what they told me, but I was so limited ⁓ for so long. Is that still kind of when they do this regular cleanup of the patellar tendon and they have to cut the whole thing, are these people laid up for quite a while after that?
Jarrod (51:56)
Yeah, I mean, we are probably the only group that I’m aware of really now that’s doing this minimally invasive procedure. It’s really just a continuation of Alfredson and Lorenzo’s work. ⁓ But traditionally, yeah, that’s what’s done. They cut it open and 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.
And 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, 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, I say this to John, 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. They do take longer to come back. And I’ve got the data of, you know, those patients that have had injections, I’ve got them in a spreadsheet and they do tend to take a little bit longer to come back.
Jake (53:16)
Yeah, when I was there, you had a footballer. I feel like, did he get a corticosteroid injection patellar tendon maybe many months or years? think so. And he had that hole that you could see. And you were kind of saying that that’s not going to come back. ⁓ Because in the tendon world, they have that hole, I guess, the donut hole analogy. And it’s like, if you load the hole, can go back to a line collagen. But what you’re saying is
⁓ no.
Jarrod (53:47)
Well, the doughnut on the whole is more that you don’t necessarily need the whole, the rest of the doughnut will support the structure. So if you load the healthy, then it doesn’t matter about the center. think for the patellar tendon, it comes down to loading rates. 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, they,
I mean, they probably won’t get back or they will always have symptoms. But more importantly, I think what’s important to notice tendinopathy, whether it be patella or Achilles is 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, you know, they, they might use shortcuts to get to places and they become less athletic. And John probably sees that a lot more than I do because he works for works for Wales. But some of the people that do suffer tendinopathy, they just
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 (55:30)
You guys, think going back to your point earlier about the blood vessels, a lot of people that we see may, you know, they’ve seen all the patients do an MRI scan in acute phase and they say, well, 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
know, surprise, surprise, the pain comes back. you know, the one of our, our big anchors of loading is the modified Kongsguard, you know, that Kongsguard paper was the three groups of peritendinous steroid, ⁓ eccentric Young’s program, heavy slow loading, which is now evolved into how we manage a lot of ⁓ our patellar tendons. And in that steroid group,
they were great at the six week point by six months back to where they were at 12 months, still where they were a year ago, whereas the two loading programs significant improvements, but the patients preferred the heavy slows to the eccentric. So I think that, you know, we try and 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 got onto rupture and
And 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 (57:03)
Mm-hmm.
Jake (57:04)
Um, you guys probably, I was when I was sitting there hearing the people’s stories of what they tried. Um, the PRP injections, even like BP is probably get the BPC 157. Uh, I don’t know if you guys, if anyone’s coming to say that I get it all the time. Um, have you guys seen any data on this BPC 157 and people like it’s B it’s magical for my tendon. Yeah. What are your thoughts?
Jarrod (57:32)
If I may, John, because I’ve had this conversation with a rheumatologist here in London. ⁓ And there’s some great, there is some good evidence to talk about the use of growth hormone in tendinopathy. And I obviously asked him about that. And he said, know, BP157 is just a surrogate of growth hormone. It’s just a peptide of, he said, do you know, 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. you’re going to do, if you’re going to do BP 157, then you may as well do growth hormone. He said the evidence is not there. He said one of the biggest issues he comes up against is the black market. So you say, get a vile sense of BP 157 who’s testing it because it’s not legal in this country. So his view was absolutely not. It’s not worth trying. It’s there is no evidence for it and there isn’t any positive evidence for it. I would probably agree with that. I’m a bit black and white when it comes to
either legality, just legalities of it. Number one, number two is if you’re going to do it, should be under somebody that knows a lot about it. And an endocrinologist is probably a good place to start. And yeah, Joe, what do think?
Jon (58:42)
Yeah, I definitely. mean, I think, you know, I work in pro sport and so we, you know, we have to sign a code against doping and all those other things. So BP 157 is a banned substance. So, you know, it’s pretty difficult for me to sort of be saying to patients, well, no, think, you know, give it a go when my world is a league sport. So I kind of distance myself from it. What do I think? I don’t think there’s any evidence for it at the moment. That doesn’t mean it doesn’t work. I think that maybe
know, peptides, there may be something in that. the difficulty is that you’re not getting, you for these problems, you’re not getting a big pharma company coming in and say, we’re going to do this RCT. You’re just getting supplement companies and others or compounding pharmacies going, we might make some money here. And that’s my concern about that whole market of it. So I think some people are potentially being ripped off with stuff that’s gotten nothing like
those peptides in. it’s not, you know, it’s not a clean, clean market at the moment. And I think unless I start seeing some really good positive scientific evidence for its use, then it will stay in there. I’m not going to touch that bin.
Jake (59:59)
Yeah. And then you have meatheads injecting, injecting into their, well, I guess it’s like subcutaneous. So it’s not directly into it, but it’s like, it just doesn’t sound, sounded right to me. Okay. I, ⁓ I’ve dealt with a few people that are like, wrestlers are like really high level athletes and they might be in organizations that things are not banned or whatever. go overseas. Stem cells. Do you guys see people come to you that have gotten stem cells in their tendons? ⁓ has it done anything positive? What are your thoughts there?
Jon (1:00:31)
Yeah, think, again, we haven’t really got a market for true stem cells in the UK. So people are, you know, if they’re doing it, they’re kind of doing it in South America and Panama, places like that. What do I think about it? I think that probably there’s, you know, there may be something in it in the same way that, you know, we do sometimes use PRP in our Achilles tendon tears, intrasubstance tears.
So some of these things may have an effect. 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. we haven’t probably seen enough of them that have come from that market to say,
any positive experience of it, that would be my take on it.
Jarrod (1:01:29)
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. because it’s in the same location, it’s going to become a tenocyte is very naive. I don’t…
There isn’t any evidence to say that we can, I mean, there’s the CRISPR technology, but it’s been shown to not be able to code. So it’s very naive to think that taking an undifferentiated cell and putting it in the same location that you want it to become cartilage or tendon, which is what a lot of people use it for, I think is really, really naive. There may well come a time, and I hope there does come a time, when we can code for it and we can take a stem cell and then make it a tenocyte. That will change things.
I think if we can make a stem cell into some cartilage cells, think the need for replacements will diminish massively because if we can grow cartilage, well, that’s why people get replacements, knee or hip replacements. you know, I think in the future when we can code for it, amazing. But at the moment we can’t. as John said, it’s an extremely expensive option. That doesn’t work. I don’t know of anybody that’s had stem cells and said it was amazing. It cured me. I know people get stem cell IVs, but
mean, if you get an IV, a good saline IV with a bit of vitamin C and something else in it, you probably feel pretty good as well. So I don’t know, I think the jury’s out and it’s extremely expensive and there are some people making a lot of money out of it with no evidence.
Jake (1:03:11)
So you said earlier about the, you’re treating, treating tenants with a conservatively, conservative management. The issue I always get is like, when I look at their conservative management, like for a patella or Achilles, ⁓ maybe it’s just not good or it’s under loaded or maybe whatever it is. ⁓ How do you guys deem that they’ve spent, they’ve done good conservative management? They’ve spent enough time with conservative management before you might.
⁓ think of doing something else like an injection or like a surgery.
Jarrod (1:03:44)
I think patella and Achilles, comes down to, that’s why we spend half an hour talking to them and getting their history is to understand what their loading is. We had a patient come in today who had quadstenenopathy and we asked him what his loading program is. He said, I haven’t done any. well, okay, so we’ll give you a learning program and that will probably give you some results. I think if they’ve done some form of heavy loading for a period of time, anywhere between six and 12 weeks, and they haven’t responded, then sure, we can try something. But
We, John and I sat down and said some years, 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 in the tele-attendant, probably 70 to 80 % of people respond really well to a good loading program. That has to be your first point of call. 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 12 weeks of it, eight weeks of it, something that’s meaningful and they haven’t noticed an improvement in their symptoms, then we could talk about something, whether it be, you know, maybe shockwave or some oral medication, or if they’re really in a lot of pain, which, you John and I have seen a few lately where they’re, you know, horrible patellar tendons in lots and lots of pain, while prolonging the agony, we take them into theater and we…
do the procedure I talked about. So they really have to have failed their exercises. But that also being said, I mean, there are those that have plantaris related that come in, they’re really sore. can see it under grayscale and UTC. And we offer them oral medication or an HA injection between plantaris and Achilles. And that gives them a lot of relief. yeah.
Jon (1:05:34)
I think going back to that point, 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…
Jarrod (1:05:47)
That’s true.
Jon (1:05:57)
It’s almost unheard of for us to not have some sort of loading in there. There’s the occasional one where we’ve seen a massive metabolic tendon that looks like it could snap if they step on the curb wrong. Sometimes we’ll just shut people down for a period of time. But 99 % of the patients that come through, like the osteoanil injection for the plantarist, it’s reducing that inflammatory response between the plantarist and Achilles in the fat pad.
reducing that pain to enable them to load that tendinopathy because they can’t at the moment because it’s too sore. It’s not going to happen. So the adjuncts are often to enable the loading and it’s not really until you get to the stage of surgery where you’re kind of going, right, this is an intervention that is irrespective of what loading you’ve been doing now. We failed, this is what we do, we move on. But even then after that,
Jared will set them the post-op loading that teaches that tender now to remodel healthily.
Jarrod (1:07:01)
That’s great.
Jake (1:07:02)
You guys had when I was there, you had a guy come in. I missed a little bit of it, he was I think he was biking was one of his activities. Suspected patellar tendon pain and you guys did ultrasound and you saw his tendons were perfect and you were thinking patella femoral pain. Do you see that often this confusion of patellar tendon or quad tendon with patella femoral pain?
Jon (1:07:25)
Yeah, occasionally.
Jarrod (1:07:28)
Yeah, I mean the ultrasound is great because it rules out the patella or a quad tendon. I think quad tendinopathy is really quite easy to differentiate because they’ll describe pain at the top of the knee and if it’s not, they don’t have any crepitus, they don’t have any telopheminal issues, you can stick your finger and yeah, it’s pretty obvious. The discrete ones are whether they’ve got a plyocut, whether they’ve got fat patty rotation, whether there is some chondral defect behind the knee and then you’ve got patella tendons.
We do see them. We’ve seen quite a few that come in and present like patellar tendon and actually they might have patellar ulta or they have fat pattiar rotation. So yeah, the history is important.
Jon (1:08:12)
Yeah, I was just about to say that normally, because we take a fairly detailed history, we’ll kind of when we’re going through to the ultrasound room, we’ll look at each other and just go, you’re not convinced by this one, there’s something that you know, and then so we’ll look more. And similarly, we see it occasionally with the like the posterior impingement at the ankle. Yeah, they’ve got a big, big posterior process of the talus or an osteotrigonum.
And it’s just something that doesn’t fit on the story. And so we direct it down a different route.
Jake (1:08:50)
⁓ one more for you guys. I went over time. It’s late for you there. ⁓ if you could go back when you guys started with tendons, ⁓ yeah, what, what was your thought process like back when you first started versus what it’s at now? And then maybe if you could turn that into, ⁓ cause I, mean, I mostly deal with like strength coaches, physical therapists, and, ⁓ it just seems like there are still not the best practices being done to rehab tendons. ⁓
Yeah, if you could maybe turn that question into what you feel like needs to be improved in the field of tendinopathy rehab.
Jarrod (1:09:30)
I might go because this is, John will be a bit surprised by this one. I think if I, if I could go back, I probably would have, have a better understanding of things that are not mechanical. So all of the rheumatological ones, because working with John for the last nine years, some of the questions and some of the medications and some of the things that people are on, you know, they’re just, loading is not the only thing. And I think,
you know, back in the day, you know, I remember just thinking this rheumatologist, you know, it’s clearly mechanical, this guy’s full of shit. But actually, there are so many patients that we see that just there is a metabolic issue or they’re gout or and so for me, I think there’s probably a few patients early on in my career where they would have, they would have, they would have definitely
responded and gotten a lot better with a broader approach to managing telemopathy, not just a mechanical approach, a loading perspective. So yeah. Did that get you, John? Are you surprised by that?
Jon (1:10:41)
Yeah, maybe a little tear in my eye. No, think, ⁓ yeah, I guess also from my perspective, I mean, this is the great thing about doing a combined clinic, right, you learn, learn so much. And so I’ve learned so much more about exercise therapy and loading and the mechanics over the years. I think that, you know, do I think about it differently now? I think that
that the problem is, is you don’t know what you don’t know, right? And I think that, you know, 10 years ago, I didn’t know half the stuff I know now about tendons. And that’s why constantly we’re trying to evolve between the two of us and now with our surgeons. And again, Jared said, now that we’re getting surgeons into the team, you know, the knowledge base across them and us about the procedures, etc, is going up. think, you know, the big thing that the
I think from managing terms outside of this super specialized, second, third opinion, chronic issues is more about just don’t hang on to it if it’s not working. If it’s not working, then you need more information and you need to think about why that is. And that might, it might not be you who has that answer. And, and I think that I was lucky to learn that lesson relatively early.
in my career that if you, you know, if you’re not winning, you need help. And I think sometimes there’s any sort of healthcare provider from physio, S &C, ⁓ docs, ⁓ surgeons, that one of the problems is, is that you kind of sometimes feel like, if I’ve got to say to this patient, you need to see someone else, then I failed and that, you know, they won’t respect me for what I’ve done, but it’s
It’s not that at all. It’s completely in the best interest. you’re not winning, you’ve got to involve someone else and a nation. Ultimately, I think they’ll respect you more for putting them at the forefront of the decision making rather than your feelings.
Jarrod (1:12:50)
Mm-hmm.
Jake (1:12:51)
last, when when I spoke to Jared last time, you made me aware of the, different, ⁓ groups in the tendon world all over the world. There’s different groups and opinions. mostly it seems around the same page, but there’s some things that people really disagree on. Well, why do you guys think there’s, there’s disagreements in the Achilles and patellar tendon rehab world?
Jarrod (1:13:18)
Oh, that’s a tough one. Why? Why? I mean, people disagree because everyone has their biases. Um, I think maybe there are people are some of the groups might be funded by. Supplement companies or whatever it be. But I mean, I think generally across the board, when you go to ISTS, I think people, there is a general consensus of
of how tendinopathy is managed. For those that are tendon researchers that really work in the tendon world, think one of the things might be the people that don’t really work in the human tendon world or the tendon world and they sort of have these strong opinions, whether it be using BP157 or doing this and that. so that social media has an influence on that. I don’t think that there’s a huge difference in opinion between the groups in the foundation of it, which is, you know,
loading. We all know that that is how you make tendons better. ⁓ But there are probably differences you might be referring to, whether it be isotonic or eccentric or isometric. There’s still loading strategies. ⁓ But yeah, there are obviously differences in opinions in that. ⁓
Jon (1:14:35)
Yeah, I think it’s a beautiful way to end because I think it brings us all the way around full circle to the sort of, why did we find these things interesting? Because 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 tender. That’s for me that, you know, it’s not straightforward. It’s not simple. Otherwise, we’d all be getting it right all the time.
Jarrod (1:15:15)
Great. Very succinct,
Jake (1:15:18)
Alright, tell them
where can people find you?
Jon (1:15:22)
So they can find us at Forteus Clinic. So we’ve got a couple of places in London. ⁓ We mainly work out of the City Clinic, which is right in the square mile of London. And yeah, we kind of, we have little pockets of people coming from Ireland and from Wales and, you know, we treat one, then they tell a friend. And so, yeah, absolutely. You can get in contact with.
⁓ Either myself or Jared at the Forties Clinic in London. We run a specialist tending clinic. Very happy to answer questions and for people who are abroad then certainly sometimes what we might consider is like a video call to start with to go through some of the history and the light just because it’s a long way for people to come if they’re coming from where you hail from. But it was great to have you in the clinic and hope you enjoyed it.
Jake (1:16:16)
I did. I gotta spend a few more days next time. Yeah. But alright guys, thanks for coming on.
Jarrod (1:16:19)
Awesome.
Jon (1:16:22)
Peace out.
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/
