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On this episode of the sports physical therapy podcast, I'm joined by Dan Pope. Dan's a physical therapist with us@championptandperformanceandrunsanamazingwebsiteandsocialmediapresenceatfitnesspainfree.com. And this episode, we're going to be talking a lot about patellar, tendinopathy, and pretty much everything you need to know about why it happens and what to do about it. Welcome to the Sports Physical Therapy Podcast. I'm your host, Mike Reinald from Mike Reinald. com. Hey Dan, welcome back to the podcast. How's everything going? What's going on, Mike? Thank you for having me. Uh, things are going quite well. Yeah. Awesome. I think you might be the first repeat guest on the podcast. I was curious about that, you know, I'm, uh, I'm more nervous than anything else. You guys have some heavy hitters on this podcast. Well, you know, it's funny, like I, I, um. Uh, I've been wanting to do this episode with you for a little bit, um, on tendinopathy, because I, I know not just because I see you at work every day. I know how much experience you have in this area and how well you do with your patients and how well you do, but you've also been just doing so much great content on your website and social media lately on this topic that, um, people just need to learn from you, man. You know what I mean? Like you're just, you're such a good mind that people just need to hear from you. So I'm excited about this. Alright. Thank you. I appreciate it. I try not to sound too dumb. I love it. But, uh, let's kick this off and talk a little bit about, you know, I don't know what you think about patellar, patellar tendinopathy, sorry, and how you think this starts, right? Like, why do people start having that issue? That's, that's something I always deal with. I had an evaluation last week of a, you know, high school. you know, volleyball player. And, you know, you wonder, like, what is it, what is it about her that causes patellar tendinopathy to start, right? She's a kid, you know, it's, you know, maybe this isn't a chronic degeneration, like sometimes we want to blame it on all the time, like, I don't know, in your experience, what, what's, what's been what, what kicks these off in the majority of your patients? Yeah, that's hard, you know, um, I can't say exactly what I know. I know there's a bunch of risk factors you'll see in the medical literature. I think the most obvious one and the thing that I find myself trying to educate students about a lot and other coaches They're trying to prevent these injuries It's just knowing the demands of your sport and if you start looking at where these injuries are occurring It's gonna be in jumping athletes, right? The big ones are gonna be basketball as well as volleyball And then when you look at things like running that have some plyometrics at a lower level and you look at something like soccer Which obviously there's ton of plyometrics there. They don't have the same rates Although this is a very common injury, so I think first and foremost, it's probably just exposures, total exposures to jumping will be my first guess that's going to be creating this problem. We also have some research to show that males had this a little bit more than females, and usually it's between the ages of 15 and 30. Um, and maybe we'll talk about this a little bit later, but patellar tendinopathy is a little bit odd when you compare it to say Achilles tendinopathy or especially rotator cuff tendinopathy, meaning that patellar tendinopathy kind of shows up between the ages of 15 and 30. And it dies down after that. And it certainly could be because people just aren't jumping as much. Like we stopped playing rugby at a certain age, right? It's not like people are doing these crazy activities for the rest of their life. Um, but Achilles tendinopathy and certainly rotator cuff tendinopathy and rotator cuff tears. So if you look at 80 year olds, right, if you don't have a partial thickness cuff tear, you're kind of a, an oddball at that point, right? So I think it's something that's specific towards jumping. It's just has a very unique stress, the tendon at the knee. And because of that, we ended up seeing this occurring more frequently in those folks. There's also a correlation between body weight and this is kind of an interesting phenomenon. And I also like to tell folks about this because As physical therapists, we're not always in this realm, but I think it's important and we can affect, um, people's success through this factor. But if you have increased body fat specifically, it increases your risk of osteoarthritis and also tendinopathy throughout the course, throughout the body. And this could be for two reasons. For one, there's more mechanical loading when you have more body fat, right? And that's obvious, more stress on these tendons. Um, but at least in osteoarthritis, there's some sort of inflammatory effect, at least we think. So essentially within your joints. If you have a lot of body fat, we may have a little bit more breakdown of the cartilage and less of this remodeling over the course of time. So over the course of time, we have net cartilage loss a little bit greater than someone that doesn't have as much body fat. But with a patellar tendon, what we're finding is that fat free mass, skeletal mass, those things also increase your risk of patellar tendinitis, tendinosis, whatever you call it. So it seems like it is the body mass in general. so maybe a little bit more of the body fat, right? But if you're a heavier athlete, you might be a little more at risk, uh, obviously because you're jumping with a little more weight, right? And that kind of makes sense. Um, I know you had also said workload is a big one. And I think that's probably part of that. Um, I know Tim Gabbitt, when he came and spoke to us a couple years back, one of the things he said, which I thought was kind of interesting, he's like, workload isn't everything, right? There's a lot of other risk factors and correlate to this. So you know me, I did a little research before this podcast just to check, check at workloads and see if they correlate with patellar tendinopathy. I did find it kind of an interesting study. This was JOSPT 2020. Guy's name is Ghali, who was the main author, and he was looking at workload in basketball players, and um, it was only one week, but what they were doing is comparing, um, folks that have patellar tendinopathy, and folks that don't have patellar tendinopathy, and seeing if there's a difference in their workloads. And looking at total jumps, they're looking at basketball sessions, um, and they were also looking at rating of perceived exertion. So they're kind of calculating the whole workload the same way Tim Gabbitt does in his original research. And they showed no correlation between the workload over the course of one week and having Peninopathy. If I had a guess, I think it's probably over a very long period of time. Um, we found that most of these tendinopathies are probably, um, tendinosis and not tendinitis. So can there be some of the acute thing that sets these things off? Of course. But is it something that's going on for years and years and we don't know about? And the more often you're exposed to jumping, the more likely you're hard to have this tendinopathy. That makes sense, right? Um, and this, there's some research in professional basketball players that are asymptomatic and around 90 percent of those guys have a tendinopathy present if you just MRI their patellar tendon. So I wonder if it's one of these things where it's been growing over the course of time. Um, and this might not be popular, but if it's been going on for longer, there's more tendinopathy, maybe you're more likely to have an exacerbation and maybe you have that reactive tendinopathy, which is kind of. It wasn't hurting you whatsoever. Then all of a sudden it starts to be irritated, um, and this can seemingly be out of nowhere or it's more often a gradual onset. Um, but yeah, that's my best guess as to why it's happening. But the other part is like, it seems like there's some other factors at play. So Dan, that, I think that makes sense to me, like you even mentioned it in the study with the basketball players that maybe there's no correlation between workload, right? So the same players have the same workload. Some people got patella adenopathy, some didn't. Should we be thinking this more as a combination of both workload and the capacity? Like maybe the players capacities were different, like, should we, should we not be thinking of workload and isolation, but more thinking about what is your workload in relation to what your specific capacity is with your body? Yeah, that's that's super important, right? I mean, I was I was talking about workload in that original study But one of the big things for Tim Gabbitt is acute to chronic workload ratio So we were just looking at the acute ratio. We have no idea what the chronic was What were these athletes used to? Right were they you know elite folks coming into it and then doing a low level of work and they're fine because of that Uh, where the people with tendinopathy actually have a, a low chronic workload. So basically what we saw was a spike for them, but not for the other folks. You know what I mean? Um, I'd also be curious too, and you know, I know I have a lot of insight into this, into throwing, right? But if we throw for 12 months out of the year, versus let's say eight, right? Are we going to be less likely to have injuries just because we have a period of time away from throwing? I would imagine that's probably similar for basketball players as well. If we have a little bit of time throughout the course of the year where we stay away from some of the jumping, we have less exposures. Maybe we have less tenanopathy and less likelihood of developing a symptomatic tenanopathy over the course of time, right? And then hopefully if you're taking some time off from that sport that requires an activity that could produce a pathology like this, then theoretically, you're building capacity and that downtime so that way when you do get back to your competitive season, your body can handle that workload more, right? Mm hmm. For sure. Yeah. So, you know, for me, I, I think that's why, you know, sometimes you ask yourself, right? Like my, you know, last week, 18 year old female, you know, volleyball player. And, you know, in my head, as I'm preparing for the evaluation, I'm thinking of all the potential things she may look like. And then. She didn't, right? Like she had the strongest quads of, uh, of an 18 year old athlete I've seen in the longest time in the world. And you wonder what, you know, why, why did she get it other than just like her workload was enormous, right? So, you know, you put, you put it all together and you take the person's capacity, their workload. But, um, I wonder your opinion on her though. And I think that leads to the discussion a little bit here. So 18 year olds never had a problem before in her life. Right. And now she has it. There's, there's been a lot of discussion over the years between itis and Like tendonitis versus tendinosis. And is there an acute inflammatory process? Is this more degenerative? Um, I know if if you follow somebody over time it's gonna be more degenerative, but do you think this is ever just an isolated acute tendonitis, or do you think there's, there's a certain amount of degeneration that's happening in almost everybody? Yeah. I gotta imagine that, you know, there's a couple questions there, but probably the large majority of people are getting some sort of degeneration over the course of time, you know? I think at the patellar tendon, a little less likely than let's say the rotator cuff, the Achilles, and I'm guessing that's just the specific nature of jumping over the course of time. Um, I think largely, and I know you'd kind of give me some of these questions to ponder before the podcast, so I did look into this a little bit, and overall it does seem largely that we believe this is more of an osis condition, and when folks are having that kind of acute pain, that's more of maybe a reactive teninopathy. to the point where now the body's like, this is too much. And, and during this reactive tendinopathy, there are inflammatory factors within the tendon, but it's not the typical inflammatory situation we tend to think about, right? Um, I do, I was thinking about this the other day, so I was looking at a research study on gluteal tendinopathy, and they're looking at greater trochanteric pain. which classically has been inflammatory in nature. Right? We always used to think, well, classically isn't believed to be inflammatory nature. We think it's a bursitis issue. And we've always kind of treated this with like a cortisone injection, right? And then basically, now that we're thinking that most tendon pain problems are more of OSIS conditions, we're starting to look at this closer and say, are actually dealing with you know, tendonitis, or is this actually, you know, a true osis? What's kind of happening? Um, and I think it was like 97, 98 percent of those folks actually had an osis condition, but what I will say is I have one patient, my schedule right now. And I see this pretty frequently where you hit them with a cortisone injection. They feel amazing. Right. And pretty much takes away the majority of their pain. So. I wonder about that sometimes. And I think one of the easier things you can do, and I say easy because it's not easy. Most of these folks are playing a lot. Oftentimes, it happens in the middle of the season. But if you just rest them for a week or two and see if that gets rid of their pain, then you can kind of conclude maybe this was more of an itis. condition. Um, but if it was more of that gradual buildup over the course of time, um, that hasn't gotten better historically with rest. So maybe tease that out in the subjective and maybe you are dealing more with this osis. Um, but I do think it is pretty realistic to just say, take a week off, see if it gets better and then try to slowly ramp up. And it feels better than great. Maybe it was more of that true itis condition. And that's something you can certainly try. It's just that if someone's in the middle of their season, that's tough, right? It's like, you got to really take them away quite a bit. And the other problem is that they might not get rid of their pain. It might just basically make them feel better. And as soon as I get back, it starts hurting again. And I think that's a problem too, you know, Um, going back to your earlier point and you know, I don't want to go too much on a tangent here but what is interesting is that there's a little bit of research and folks have teninopathy, they jump a little bit differently, right? They actually have more of a knee flexion moment so they're using their quads a little bit more so, right? So in your earlier example of the female athlete super strong quads, there is a thought that these folks just like using their quads more and they also like using their tenons more potentially. And it's hard to know exactly why this is, but we've got a little research to show that folks that have tendinopathy on average have higher jumping abilities, right? So, at least in my mind, the first no brainer that comes to mind is like, all right, they're better jumpers. They probably jump more frequently, right? And then they're maybe more exposed to jumping and because of that, they have more tendinopathy. But maybe these folks are better at loading up their tendons. Maybe they call on their tendons a little bit more so, and they're more likely to have tendinopathy. So these folks are very strong, great jumpers. Maybe that's just because they're been stressing their tendons and they're a little better using them. I don't know. So you also have the argument that from a rehab perspective, we can alter their jumping and you will see some case studies, case series out there. We're that successful. So folks are kind of in season. They practice jumping in a way that creates more of a hip moment. Arms are saying hips back when you jump and land trying to reduce some of the stress on the patellar tendon. And that does seem to be helpful, at least in those case studies, right? So I think that is an argument you can make. These folks are maybe overusing their patellar tendon. That's why it hurts. So, yeah, and I wonder if that goes back to capacity again, right to their body doesn't have the capacity to do a good, you know, hip moment during their, their jump. So maybe they're overloading with the knee moment and they're doing too much. I can see that being a potential capacity issue as well. So, yeah. So, so what do you think? Somebody comes to you, they're, they're in your hands. I kind of like how you talk subjectively about like has rest helped in the past. I actually thought that was, you know, really good insight. If it, if it cleans up with a little rest, and I know when you say rest, you don't mean bed rest. Like there's, there's exercise and there's treatment going on there, but if it cleans up, that's pretty good. Like what are some of the other things you're doing in your examination? Right? So like when somebody comes to you, what are some of the things that specifically you want to look for, for patellar tendinopathy? How do you maybe, you know, differentially diagnose it? from other things in the knee, like other types of patella femoral pain. Like, where do you tend to go with your exam? Yeah, for sure. And I kind of start like a regular physical therapy examination where you talk a little bit about the subjective history, you know, I think a lot of it is with patellar tendonitis, tendinosis, whatever you want to call it, usually it's a gradual onset, not always all at once, but it certainly can be sounds like for your athlete, it was fine. And all of a sudden it wasn't to kind of one jump goes wrong. All of a sudden you're feeling a bunch of pain in that area. Right? Um, but largely I'm trying to rule out more serious injury, right? Was there a twisting mechanism? Was there any swelling? Did you feel a pop? Right? Those types of things. So we want to make sure someone's not dealing with some sort of ACL tear, MCL tear, not dealing with a meniscus tear, something like that, right? And I think you get a lot of that information from the person that's in front of you when you start talking to them. Um, and we'll get to this a little bit later, but they're going to point to where the pain is and I think that's kind of the biggest indicator, right? Um, but when we get down to the objective portion, I take that person through a range of motion testing. So if someone's dealing with tibial femoral joint pathology, so I'm thinking meniscus, maybe cartilage, maybe some instability, something going on there. probably going to see some pain, either end range flexion or extension, right? And then generally speaking for patellar tenonosis, tenonopathy, you're not going to see that, right? The other thing for patellar tenonopathy is there's usually no pain at rest. So if you have someone who has an irritated knee just sitting there, probably not dealing with the tendon issue. Right. And then from there, I just do my joint pathology test. So joint line tenderness, McMurray, whatever you want to do to try to rule out, especially looking for swelling, usually with patellar tenopathy, you're not going to find any swelling in that area. And then once you've kind of cleared that stuff, there's a few diagnoses, I guess it could be. So you kind of dealt with more patellar femoral pain, right? Versus more of a patellar tendinopathy. Uh, maybe in younger athletes, you're also looking for Osgood Schlatter's. right? And I think the thing about patella femoral pain is that usually it's diffuse. It's usually somewhere underneath the kneecap, right? But oftentimes it changes. So athletes will say sometimes it hurts right on patellar tendon, but sometimes it's behind the kneecap, and sometimes it's even above, right? So for patella femoral pain, I think oftentimes it's not going to be as simple as my pain is right here on this spot. Sometimes it moves around a little bit. And then for patellar tendinopathy, the large majority of folks think it's like 65%. Um, we'll have pain at the inferior pole of the patella. So right where that patella tendon attaches, around 10 percent of those folks will have pain on the tib tuberosity. But I think you have to differentially diagnose for those folks to think about maybe this is an Osgood Schlatter's, right? Which you're maybe noticing a little bit more pain on the tib tuberosity plus a little bit extra bony growth. Usually those folks are going to be a little bit younger. right? Um, if someone's like 20 plus, I'm thinking more patellar tendinopathy. If someone's under the age of, let's say, 15, I'm thinking more Osgood Schlatter's, right? Um, and then I think the, uh, the other piece that we didn't talk about is that about 25 percent of folks with a jumper's knee. So that's going to be pain directly above the kneecap. Um, but with tendinopathies in general, and I think jumper's knee is one of those things. Usually people can take one finger and put it right on the injury and say, this is where it hurts. And usually it doesn't change at all. Usually it doesn't jump around like a patellofemoral pain does. Right. And the next piece is that when you start loading it. it. Usually more load means more pain, right? So for something like a meniscus tear, oftentimes they have a positional problem, meaning that if you do a bunch of exercises with the knee in like minimal degrees of knee flexion feels pretty good. As soon as you go into a deep squat, it feels horrible. And it's more about the bend of the knee going to the end range that hurts. For patella tendinopathy, the more you load the quad, either with more load or more speed, the more pain you're going to get usually. So if I do something like a pogo jump, maybe it hurts a little bit. If I do something like a higher pogo jump hurts a little more. And if I do a single legged pogo jump hurts the most, right? And you should see kind of a linear correlation with that. Those would be the big ones. That's a good, I think that's a great way of differentiating too. And again, this is, you know, for all the listeners again, this is, this is why I wanted to do this episode so much. I knew, I knew Dan would have like a dissertation on, on these answers, like in such an amazing way, right? So, I mean, that, that was, that's a pretty comprehensive approach, right? Hopefully you got. Quite a few pearls out of that. I know I did. Um, but I love the way you, you, you identified specific things that do and do not correlate to that. So that way you can kind of like roadblock it a little bit. So, um, I love it. I think that's a great way of looking at it on the examination. Let's shift gears. Let's talk treatment. So walk us through your approach a little bit again. And again, I know that's a huge question, so I apologize, but I, I give you huge questions because I know you're going to have awesome answers. So I don't have to lead you that much. Um, but you know, when, when you get into treatment, like what, what's your game plan here? And when you, like, what are you expecting to do at the beginning of this process? And does it change based on how acute or chronic it may be or, or what they're doing with their activities? Walk us through a little bit of your, your approach. Yeah, you're right. That's a that's a big question and a good one because we can talk about exercise treatments We can also talk about things like injection shockwave, you know potential surgeries 10x There's there's all sorts of things we can kind of try Which I think is useful because a lot of PTs are like once they get through the whole exercise thing and they haven't had any Solutions or like I don't know what to do for you So that might be something just touch on I'm not an expert there, but at least I can help guide a little bit I think the first one is what kind of exercises are most helpful for these folks, right? And it really seems like loading for the tendon is probably going to be the best thing for patellar tendinopathy, right? A lot of folks will make the argument that you need to train the hip. And I would also say that that's probably beneficial, um, particularly if you have an athlete that you feel like they're overusing their knee extensors, right? Um, but I also will say that I think that should be done in conjunction with some sort of loading to the patellar tendon. Because let's say that their strategy revolves too much around using the quad. Let's maybe change that strategy a little bit, but let's also load the quad tendon or the patellar tendon So over the course time pain kind of goes down and I think what becomes confusing for students We thought we talked about this a little bit on the Mike Reinald show is what kind of contractions are best Um, because if you talk to a lot of physicians, it's kind of like you got to do eccentrics and that's like the hardest thing you could do, right? You need to do your eccentrics and then, you know, heavy, slow loads. There's a big paper on that and everyone's like, oh, we got to do heavy, slow loads, right? That's important. And then we had some research about isometrics and it's like, oh my God, isometrics too. We got to do isometrics. So I think it's just regurgitating the latest article, right? I know. Yes. That's kind of what it becomes. And what I will say is that. Most of the research on treating patellar tendinopathy in the long term is more going to be eccentrics, isotonics, as well as the heavy slow loads, right? Right. We've had some more recent research and I think this is great. So they're looking at heavy slow loads versus moderate loads. And found the same outcome. And then we're also seeing the same thing occurring with BFR versus heavy loads. Same changes within the tendon, differences in pain about the same. And I think for a lot of students, this is frustrating, right? You're like, what's the best treatment? Like, what do I do? Right? At least for me, that, that's awesome because I have a lot of options now. I think that's important. Um, largely because you're going to be dealing with patients all along different spectrums. And that's going to be different sports, different activities. You're going to see some, um, athletes are in season versus out of season. You're going to see some folks that are going to be minimally irritable. You're going to be some folks that are super irritable and we just have to meet them where they are in terms of exercises, right? So largely when I'm doing an evaluation, I'm asking a lot of questions about their goals. what's going on from a sports season, um, uh, setup, right? Are they currently in season? Are they're already pounding a ton of jumping and, you know, sports activities where I can't really afford to put some heavy, heavy load on that person and do a bunch of plyos because they're already overdoing it. Uh, and I think you will see in our patellar tenopoly literature, if you just blankedly apply a strengthening program on top of an athlete is already doing, it tends not to work as well. We probably have to do some sort of activity modification, right? So I kind of think that this patellar tendon has only so much it can handle. And if I'm already doing a ton of sports. I can't afford to do much more heavy loading on this. So for one of those athletes, I will try to activity modify as much as I can. So maybe I pull back a little bit on practice frequency, maybe we sit out on some of the less important games so we can be more available for some of the, you know, more important games towards the end of the season, right? For these folks, I would probably consider something like blood flow restriction training a few days per week, because it's relatively a lower load, right? And go kind of slow and we can still get some adaptations with the tendon. Um, I don't have to go heavy, slow loads. I don't have to do eccentrics with those folks. I don't have to get a bunch of pain for those guys, but flip it a little bit. And let's say I have an athlete that's in their off season, not playing very much. Their pain levels are not that high. We can probably get after it a little bit more. We can build a little more strength. We could do more eccentrics, right? Um, we can do more heavy loading from the standpoint of squatting, lunges, step ups, heel taps, all of that stuff. We can probably afford to incorporate more plyometrics. We probably work on jump technique a little bit more. We kind of set that foundation for more change just because we're not in the middle of a sports season where there's a million things we're trying to control and we're trying our best not to kind of piss off, the knee, right? Right. Can I talk a little about isometrics? So I feel like they're kind of oddballs too. Why not? And this is, you know, I, I looked into this myself too, because, you know, I'm a social media guy and I follow people online and I'm, I'm like getting caught up in this whole whirlwind of isometrics and like, what is all this hubbub, right? They got hot there for a second on Instagram, right? Yeah, it got hot. And I think the big one there's a I feel like we took a step back there, but okay. Yeah. Yeah. Um, one, I think they can be helpful. I think they got really popular back in 2015 with, uh, Ebony Rio. So she did a cool study with volleyball players. And the volleyball players have patellar tendinopathy, uh, kind of a small sample size. I think that's important because further research didn't show the same thing that she kind of found. Uh, but anyway, they did a step down task. I don't slam board. I believe they just asked the athletes how much pain they had. Average pain was a seven out of 10, right? So pretty dang high. And then they did five sets of 45 seconds, an isometric knee extension. I think it's 60 degrees with 70 percent MVIC. So they just put pads on their legs and they're kind of measuring EMG and they're at 70 percent of their max. And they perform that. And then after those five sets of retested, the step down task, What they found is that the pain was close to zero, right? So they substantially reduced that pain. And they also had another group that just did isotonic knee extensions, right? And what's interesting is that that group did almost as well. They didn't have the same decrease in pain, but close. Their relief didn't last as long, so the isometrics did a little bit better, right? And then the group that did isometrics had some cognitive changes as well. So, uh, Ebony Rio kind of made the conclusion and rightfully so from that paper that the isometrics are probably a little bit better. Uh, what I will say is that they tried to repeat that study. with patellar tendinopathy and they have not found the same thing. They found that the isotonic were as good as isometrics. What's funny is that Ebony Rio seems to be pretty good at reproducing her results because she did the same thing in the Achilles tendon. But the paper right before what she wrote. show that the isometrics made some folks worse. And the trend was that most people got worse with the isometrics. You know what I mean? Um, so I think the takeaway is that isometrics may be more so than isotonics. Although, you know, we don't know that for certain, those things tend to warm the tenant up. So tenants have a warmup effect. So if you do a bunch of isometrics or isotonics before your sporting activity, You tend to feel a bit better and that's kind of a no brainer. Like how many folks in the gym say they have to warm up their shoulder for 20 minutes and after they warm it up, they're pretty good, right? You hear that all the time. So that's probably occurring to the patellar tendon, other tendons across the body. Um, I think the practical takeaway is that if you have an individual that's really painful, they can't either train or they can't do their sporting task. You should trial some isometrics and as well as some isotonics and see if that helps them, right? Right. Because I've had athletes and this is the same for me because I've had Achilles tendon pain off and on for a while. Uh, but when I had Achilles tendonitis, I'm like, all right, let's warm up this tendon a little bit prior to going on a big hike. And I tried to do some isometrics and it just killed and then I couldn't do the hike, you know, Um, and maybe I couldn't do the hike anyway, right? But the other part is that that's similar some of the research kind of shows and you look at the scatter plots of these studies And what's interesting is that the trend is like maybe positive, but you'll see people that do extremely well with isometrics, you see people that get a lot worse, right? So I always tell folks, yeah, just try it, see if it helps them out. And if you find that it makes a big change with your athletes, then you can kind of prescribe more isometrics beforehand. But if that athlete is already not that irritable, and they're able to do their training without any pain, then you can say maybe we don't need the isometrics. Because I think the thing that I tell clinicians a lot is that. Isometrics are not very sport specific. And I think from a rehab perspective, you're trying to give folks movements that are very similar to what they're trying to do from like a performance standpoint. And if all we're doing is isometrics, we're not really accomplishing that. So I think it makes sense. Isometrics are not that stressful on the tendon. There's no movement, right? You're not having that. Tendons store elastic energy like you do in something that has more movement. They probably fit well as a warm up or they fit well in the beginning stages of rehab. Uh, later stages of rehab, I would say make the argument for more sports specific tasks are probably a better use of your time. And I don't know that isometrics are like the panacea, but they're definitely useful in the right person, the right time. Yeah, and try them when it's appropriate, right? I mean, you could have like a little bit of an analgesic effect. You can actually, you know, argue that somebody that's really acutely inflamed, like that time under tension is probably helpful for, for, you know, that. But again, just like everything else, you see some people applying it different, right? I see people on social media, they're doing, you know, five reps of 30 second Spanish squat holds, you know, for patellar tendinopathy, and the person's not getting better. And you're just like, well, are you underloading it? Are you not doing the right specific movements? Are you actually, is that actually overloading it during that one exercise? That's a lot. It's a lot of time under tension for the battalor tenant. So, five seconds to like, that's a lot of time requirement. Like if you're having, it's like 20 minutes of like, I don't know, it may be not that long, but it's quite a bit of time. It's a long time to be doing that. Yeah. And, and think about how much stress that is for the attendant. Then, then you actually wonder how much stress you put on the patella femoral joint. Now, you know, it's just interesting, like doing this or just that sort of thing. So it just like everything else, there's, there's a time and a place for everything, right? I think you and I use this fairly well. I think we've both read the research. We've talked about this. We've done it in other podcasts, but you know, the spectrum of isometrics. The isotonics to heavy, slow to eccentrics. Like there's a time and a place for all of them. And we probably should be doing all of them. Um, and you know, they just, they just have different, uh, benefits at different points in time for each person. Right. Yeah, I agree with you for sure. Awesome. All right. All right. So that's loading. I get it. Um, you know, we get them back into that. Talk to me about like your return to play stuff, right? For me, I think that's interesting now. Like, you know, we've loaded it up. Obviously you've worked the area of if you found any deficits, those are the no brainer ones, right? Like you're, you're already working on that. We're assume you're doing those sorts of things, but now it's time to get them back. Right. Like what's your return to sport progression look like and how do you assure that they have like a good workload progression without overdoing it? And, you know, and I want you to touch on pain a little bit here too, because you mentioned this earlier that, you know, do you work through pain is zero out of 10. Is that realistic? But like when somebody is coming back, what is your head at with that sort of progression? Yeah. And I think that's tough because what I will say is that most of the folks I'm working with are already in the middle of a sports season. It's got to have the right mass. Um, so let's, we'll kind of, um, we'll, we'll talk two scenarios. So one, you're kind of middle of a sports season, which is I think what the majority of folks are going to end up seeing, right? Because these folks are usually kind of ramping up to something and then the knee pain ramps up with it. Um, just because they're actually kind of going into their sport season and then in the sport season and the pain kind of correlates with all of that increased workload over the course of time, I would guess, right? So I tend to see, um, for tendinopathies in general, I like the pain monitoring model. And this has been studied in the patellar tendon, Achilles, all areas of the body. And I think more or less for most of the research I'm seeing on Achilles tendon pain, this is kind of the guideline they follow. Um, so generally speaking, they want to reduce the activities that create more than a five, outta 10 pain-wise. So not more than equal to or more than. So if it's a five outta 10 or it's above it, we scrap it. Right. And that could be jumping, that could be running, it could be a wide variety of tasks. Right. Um, and that's hard to do in the middle of a season. But best case scenario, you try to reduce things to create more. Than that four outta 10, right? And all activities that are still tolerable, four outta 10 or under. Then we can probably continue doing those things as long as, and we don't know this for certain, but the next day you're more or less. back to your baseline, right? And some folks, they push the envelope more. And they get better over the course of time. And I think for some folks, you have to dial back even more so than those guidelines in order to make it work. So I don't think those are hard and fast rules. But I think it's useful just because we probably don't have to completely eliminate all loading for our athletes in the middle of season, right? Let's try to keep their conditioning up a little bit. And you had kind of alluded to this, but if you take someone and take away everything that they're doing, they're going to get super deconditioned. And when they return back to their activities, it's an enormous spike. So I like to try to maintain their fitness as much as I can, right? Maintain their sports participation as much as we can. I just will say if you've got some young kind of knucklehead. Athletes in high school, you know, knuckleheads, not really fair, you know, but there's a good chance. You're just going to keep working through pain. There's a lot of tough pressures they have from a performance perspective, coaches, families, like it gets really messy there. Um, so I would say that sometimes pulling out of sport is useful just because they have a hard time regulating all of those things. But if you can regulate those things, you have a good coach on board, then I would try to, um, you can also maybe reduce the frequency of their practice participation. So if they're doing a little less throughout the course of the week, it might be a little bit more. helpful, right? Um, and then I would just try to load them with something that doesn't create too much pain and kind of follow those same guidelines. So in season athletes do pretty well with things like blood flow restriction training, that type of deal. Right. Get their pain levels down and then I want to try them a little bit in the gym. So how does it feel to run? Has it feel to jump? How are we doing with all those activities? Am I noticing any major, you know, asymmetry issues is someone now loading completely on one side. If you have access to something like a force plate like we do, I think that's really, really useful. So you can see if they're jumping a little bit more on one side versus the other. Are they twisting? Are they trying to adapt like a hip strategy on one side and knee strategy on the other? Right. I think it's probably useful to look at strength. Are they starting to rebuild symmetry side to side, right? Um, I am a believer and I would love to have this before turning to sport, but I don't feel like it's always reasonable. We'd like to be able to perform plyometrics without pain, right? So if you're doing any sort of hop testing, whatever it is, uh, we want to see that people have symmetry, but we also would like to see minimal to no pain. ideally. I just think that's not always realistic. Um, oftentimes I'm trying to get these athletes through their season and afterwards we'll kind of pick up the pieces and make them feel a bit better. Right? Yeah. Um, they don't have breaks in their seasons though. Like they, like we used to, that's the crazy part. And you know, I had that conversation with my Val from the other day, just to keep tying it back into it. A case study thing, but you know, she's got 10 more days left in the season. And I'm like, all right, like you're not going to hurt yourself. Just work through this and we'll pick up the scraps. But you know, there's another season right around the corner that is going to continue following that. And it's so hard to find time for that, that sometimes I feel like we have to help navigate with them. What's the important times to be pushing it and what's not the important times to push and maybe where you have to optimize your body, but that's always a challenge. Yeah, I agree with you. Um, very challenging. And lastly, it mentioned kind of maintain your acute acute to chronic workload ratio, right? So for some that's in season, best case scenario, you maintain it as much as you can. So I think for sports, particularly like basketball, maybe lesser extent volleyball, but certainly something like soccer, where VO two max is extremely important. And we have some literature to show that if you return folks back, with a lower VO2 max, they're more likely to have an injury. I think maintaining that conditioning is very important. So if you're taking away a lot of their gameplay and training, you probably need to put in some additional conditioning in the form of something that's a little bit lower level. So if they can get away with something like jogging, great. Um, but something like bike would be helpful if they can't tolerate a whole bunch of running, right? And once they're able to tolerate more running, you should probably incorporate more change of direction, agility drills. They tried to build up some of their tolerance and capacity. So then when they return, they're ready, right? Again, it's super messy. Um, but when someone is in an off season and they actually have more time. to think about their training, right, I would probably pull out a lot of the plyometric activity, a lot of the jumping, and I would focus more on the strengthening, I would try to get that pain down to zero. And then we incorporate plyometric slowly over the course of time, we start to ramp up their conditioning, making sure that we have everything in place so they don't have a huge spike in acute chronic workload ratio gets way easier when athletes aren't. Uh, in season, but like you said, and maybe this is the other reason why I see so many folks that are in season is that the athletes we see, they don't have an off season. They literally just play year round. With so many different sports and oftentimes the same sport and that can be very challenging to awesome. Well, dude, I think that was amazing I think you know That's a great starting point for a lot of people to I think deal with patellar tendinopathy a little bit better in their own practice Um, you really should check out fitnesspainfree. com and just go to the search bar and type in patellar tendinopathy or achilles tendinopathy or whatever it may be. Um, and Dan's got so many good masterclasses and stuff on this and tons of great free content on his website to dig in a little bit deeper. But I know that was a really helpful podcast episode for people, Dan. So, so thanks for that. You know, we got to do the high five though. And you know, as a repeat guest, we get to hear some new answers, hopefully for you. I didn't prepare for this. I forget the high five. I, I'm gonna, I'm gonna go back to our last episode and see if you duplicated any of the answers afterwards, but, but we'll see, but, uh, all right, five quick questions, Dan. Ready? What are you currently working on for your own con ed? Yeah, so I'm doing a really big thing on cervical radiculopathy. I've been asking a lot of questions about what the listeners want to listen to. And C and cervical radiculopathy is a big one. And to be honest, uh, it's a big one. So I'm, I'm doing a lot of, you know, lit review right now and just kind of going through it as best I can. Hopefully I'm looking good. I mean, I, I, for me, it just, in our practice with athletes, I don't, cervical issues aren't a high amount of our caseload. So you do feel like you get rusty or you're not up to date with some stuff when you see him. So I love that you're doing that. So great. Yeah. You're gonna, you're gonna be working with all the necks now at Champion though. Yeah, good. Hey, you're ready. But, uh, what's one thing that you've recently evolved your thoughts on? Man, recently evolved my thoughts on. Other than isometrics, which you just kind of alluded to fairly well. Well, we just got a shockwave machine, right? That's pretty cool. Um, and we didn't talk about this much, but when people have tendinopathy, we can do exercise and physical therapists, it's kind of like. What we know like our new exercise, but the other part is there are some other pretty good treatments, one of which is extracorporeal shockwave therapy, PRP, we've recently had some patients that are physicians. So I think that I've become more open minded to additional treatments outside of exercise. Not that I, you know, was in the past, but now I'm just learning more about it. Developing alliances with other practitioners, and I'm just more apt to try other things and to refer out, right, to those guys, because that can be like a no brainer and very helpful for folks. Um, and I think sometimes we're, as PTs, we're stubborn or just don't know about it, and because we don't know about it, we're a little fearful about referring out. Um, but yeah, additional treatments like that can be very helpful. Um, so that's one of the things I'm doing more of right now. Yeah, I like that. That's, that's good. Uh, what's your favorite piece of advice currently that you give our students? Mm, gosh, yeah, that's a good one. Um, I think patience. is important. Right? Um, one of the things I find myself saying to people a lot is that, you know, students get frustrated because they don't feel like they're as good as they want to be. Right? And they end up getting this imposter syndrome, which you hear all the time from students. Um, if, if a student came in, the piece of advice I give is if a student came in and they were good at everything, Be like, wow, that's weird. I don't know why this person's so good Right? I, I think you gotta expect to be bad, right? And the other thing is that making mistakes is part of it, right? And you're gonna fumble and that's okay. And you can't, can't expect to be perfect from the get go. And that's just serves as more motivation to, to get better, right? And you can kind of see where you stumble along the way and try to put your education there and you know, so I think that's a big piece of information I find myself giving a lot. I love it. What's coming up next for you, Dan? Hmm. So I'm redoing my certification, but doing a lot of market research, kind of figuring out what people really want to learn more about. I think the big problem right now in the PT world is all the students that are graduating. There's a few problems. One loans are astronomical, right? That's a problem. A lot of folks, when they graduate, they're not really working with the populations they want, right? So they go to an outpatient and they're working with mostly, let's say, geriatrics or whatever. Not that that's bad. Some people love it. Some people really don't. They want to work with a very specific population. The other piece is, it's kind of this like, mill mentality, right? Um, a lot of folks don't like the whole mill, seeing a million patients, right? Trying to bill as much as you can, that type of deal, so. The certification, obviously, I'm teaching people to be experts working in strength and fitness, right? That specific population. But also, how can you see more of these patients, right? How can you make more money? How can you kind of transform your life as a physical therapist? Because I forget this sometimes, but the setting that we work in, right? You've created this amazing place where all the. You know, practitioners come in and they're treating the people they want to the way they want to, right? We're not like, you know held back by insurance companies or just a model that prevents that so Trying to spread more of that because I think really what you create a champion is something special. It's kind of crazy I mean we had And we haven't had any therapists like leave up until this point, right? So it's crazy. Like Champion's been around for this long and no physical therapists have left. Um, so I think that's a true testament to what you've built. So trying to, you know, spread some of that information to help other therapists really enjoy their career more. And that's going to be huge for people. So, uh, definitely check that out. I'll put some links in the show notes, that sort of stuff, but Dan, where else can they learn more about you? I know you're, you're kind of, you're, you're like me. You're a little prolific, you're everywhere, but where can people find you the most you think nowadays? Yeah, I know people don't like this, but I still think the best place is going to be going to my website and signing up for my newsletter, right? Because I just deliver everything, every week, um, and I got this, I stole this idea from you, Mike, I just make a newsletter that I would actually like to read, right? And every single week, all the most important, yeah, right? I'm just giving you the most relevant stuff. stuff from all my social media platforms all in one place. So I just opened up Sunday morning. Oh, look, look at this stuff. And you can kind of consume it over the course of the week or just right there. See what you like. See what you don't like. Um, but yeah, it's, it's, it's a learning experience where I'm trying to be as helpful as possible. Um, get on the social media bandwagon. If you have specific questions, I'll answer them. There's a good chance I'll make a series on that pathology that's two hours long because I'm a nutcase. So if you really want to learn more, you can ask me and I'll do stupid stuff like that. I agree. He will. I've seen him do it. It happens. But, uh, Dan, thanks so much for your time on this. Please everybody head to fitness pain free. com and, uh, and learn more about that. Get on Dan's newsletter and stuff, but you won't regret it. I promise you. But Dan, thanks again. Maybe we're going to let time pass, but will you be our first person for a third time on the episode? I don't know, man. A lot of pressure. A lot of pressure. I would love to come back, but yeah, that would be amazing. We'll see. Awesome. Well, thanks for joining us again today, Dan. Yeah. Thank you very much, Mike. A big thank you to you and the whole audience. Much, uh, much appreciated. A lot of gratitude.