Talking Tendinopathy – Key Insights from a Podcast with Dr Ebonie Rio

Stepping into the world of tendinopathy, particularly that of the Achilles, can be filled with uncertainty. So we asked world-renowned tendon expert Dr. Ebonie Rio to sit down with us and unravel the intricacies of Achilles tendinopathy. From pinpointing a diagnosis to personalised treatment pathways, Dr. Rio provides a roadmap for clinicians and patients navigating this tricky terrain. Ebonie nails these topics and more in Episode #1 of our podcast Physio Explained – where you can learn from the best in 20 minutes or less.

Understanding tendon load and differential diagnosis

When embarking on the treatment of Achilles tendinopathy, it’s paramount to start by truly understanding your patient. As Dr. Rio emphasises, listening is a skill that brings dividends in diagnosis. She points out that tendinopathy presents with localised pain in response to high tendon loads, distinguishing it from pain that may arise due to other reasons, such as for low-load activities. Most importantly, misdiagnosis of tendinopathy can lead to poor rehab results.

By recognising the specific type of tendon issue at hand, one can tailor the management plan more precisely. The Achilles tendon, for instance, is used like a spring throughout our lives, necessitating different treatment approaches compared to other tendons that might only be engaged during specific activities like jumping.

High tendon load activities and their impact

Dr. Rio sheds light on the unique characteristics of tendon load. High tendon load is integral to fast activities — think of a sprinter’s explosive take-off or a dancer’s leap. The Achilles is central to these movements, functioning as a dynamic spring. Dr. Rio also brings attention to the importance of recognising compressive loads on tendons, which, when managed appropriately, can significantly alleviate pain and assist in rehabilitation. Compression can occur from not only footwear but positional compression caused during movement and exercise. Think about the Achilles insertion compressing against the calcaneus at the bottom of an elevated calf raise (i.e. in dorsiflexion).

Treatment approaches: Isometrics, eccentrics, and Heavy Slow Resistance (HSR)

In the realm of tendinopathy treatment, Ebonie advises against sticking rigidly to any single exercise protocol. Instead, she advocates for a diverse toolkit of exercise options. For instance, an ultra-marathon runner with a deficit in calf raises may benefit more from direct strength endurance work than isometrics. Isometric exercises, on the other hand, can be an excellent starting point for those with fear of re-injury, helping to build confidence in the safety of load-bearing. A highly personalised treatment for each individual patient is paramount.

The role of pain in tendinopathy

A nuanced understanding of pain is crucial in tendinopathy management. Dr. Rio points out that tendon pain typically warms up — it starts as stiff and grumbly but then improves with activity, a characteristic that helps differentiate it from other issues like peritendinitis. Peritendinitis pain, for example, might escalate with continued activity, leading to worsening symptoms the longer the activity is sustained. This distinction informs not only diagnosis but also patient education on what to expect during and after exercise.

Evolving management strategies

Dr. Rio highlights the importance of recognizing the brain’s role in pain production and the necessity of incorporating this understanding into rehabilitation strategies. Acknowledging that pain is produced by the brain to protect the body, rehabilitation now needs to address not only the physical aspects of tendinopathy but also the central nervous system’s involvement in the condition.

Common misconceptions and terminology

The language we use can shape a patient’s understanding and expectations of their condition and treatment. Dr. Rio stresses the need for clinicians to use appropriate terminology that reflects current knowledge. Moving away from outdated terms like “tendinitis” avoids implying an inflammatory process that could misguide treatment towards rest and anti-inflammatories rather than beneficial exercises.

Advice for new graduates and misdiagnosis issues

Misdiagnosis can lead patients down a rabbit hole of ineffective and costly treatments. Dr. Rio’s advice to new graduates and seasoned practitioners alike is to be meticulous with their diagnostic process. She shares the critical point that tendinopathy should not move or spread, which is vital information when assessing pain behaviour and planning treatment. Misdiagnosis can lead to inappropriate management strategies being applied, prolonging the patient’s rehabilitation journey.

Wrapping up

Achilles pain is a common condition that affects everyone from weekend warriors to elite athletes, so it’s crucial to stay informed and up-to-date with best practice. The key points from this podcast are:

• The tendon acts like a spring and high tendon loads increase symptoms in tendinopathy cases.
• Heavy resistance training does not qualify as high load for an achilles tendon.
• Insertional tendinopathies and mid-portion tendinopathies can present differently and require nuanced rehab.
• There are dichotomous differences between true tendinopathy and peritendinitis, it’s crucial to identify these. Pain patterns and aggravating factors are key for diagnosis.

If you’d like to see exactly how Dr Ebonie Rio assesses Achilles Tendinopathy, we have just released a 1-hour Practical with her on this topic where she takes you through her assessment approach for this tricky condition.

Check out a sneak peek of her Practical below!