What else have we seen in the last five to ten years or so that's been a radical change in the way that we manage tendons?

I would say probably nothing that you could describe as radical and very different.

I think probably isometrics might be one that qualifies.

But what happened was we had this isometric problem.

uh study that came out in 2013 that showed that isometrics are helpful for reducing pain in the short term and it also in parallel to that was a reduction or a reversal in inhibition in the brain in the motor cortex And that sparked a lot of interest in isometrics.

People started using it a lot.

And now, you know, science is self-correcting and we're seeing now that maybe we're a bit too... enthusiastic and and maybe there isn't that much difference in the isometric in the effect in short-term pain isometrics versus other exercise it seems to be that you'll get similar responses if you just load people progressively so that what that has been a really influential thing that people have taken on board a lot and I guess it's one of those things that happens.

Do you recommend any type of scan over another at the moment for someone who does have a chronic tendinopathy?

So, um, before we dive into that, can you give the, the audience a little bit of a, a, maybe a background on what shockwave therapy is and, and the potential, um, theorized mechanisms of, of what it does and, and how it could be potentially helpful in tendinopathy cases?

Yeah, for sure.

So basically, shockwave therapy is a, uh, modality that, um, is quite popular.

It's been around for, um, geez, I wanna say about maybe 25, 30 years in terms of, uh, management of tendinopathy.

It, it o- originally was used, um, and they used to call it lithotripsy, where they would use the shockwave to break up bits of calcium, um, in things like kidney stones.

So, uh, and that, that was sort of the or- the original use.

And then because tendinopathy sometimes has calcium deposits, people then started using it for tendinopathy as well, and this is going back decades.

Y- you kind of alluded to it are really, already, and, and the title kind of says it as well, but what was really the purpose of this piece and, and how did y'all end up kind of accumulating the, the papers and, and what did you end up funneling from the number of, of pieces going into this review?

Was she one of the early pioneers in evolving our thinking? Do you feel?

Absolutely.

Yeah, absolutely.

So I think if you look at the history of tendinopathy, Back in when we first started learning about these conditions, we were thinking inflammation within the tendon.

So you just need to take some anti-inflammatories and rest and you'll be better.

And then people like Hocken Alfredson, Jill Cook changed that.

People like Nicola Mufuli as well, where they started researching tendons and also Karim Khan back in those days changed researching tendons, seeing that actually it's not that simple.

So how are you now thinking about loading tendons? And there's all sorts of different types of load that you can think about when you're putting, when you're trying to exercise a tendon.

Do you, do you think that's a fair conclusion or is that way too simplistic?

I think that, uh, that is a fair conclusion.

I think you could even go a step further and say, look, uh, we at the moment, we are at a point where we have lots of things that we've tested, and we've tested exercise, we've tested, you know, other adjunct therapies, um, and we don't actually know, uh, if one is better than the other.

And we don't know if, uh, we don't know if, we don't know, you know, as you alluded to, how-- if exercise works, how much it works.

One of the questions that I think is really important for us to answer is how much specific effect is there from exercise? Is exercise working, and what are those specific mechanisms? So, uh, with, you know, with exercise, we think, and this, this is something that, uh, you see commonly and you hear it commonly, exercise is the best treatment or is the most evidence-based treatment.

But really, uh, it's, um, it's, it's just because we have a lot of exercise trials.

We have a lot of trials saying that exercise does something over time.

Yeah