Ep 278: Managing the uncertainty of tendinopathy, with Max Hopes

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[00:00:56] As a clinician, I like to be really open in my discussions with people and kind of acknowledge the uncertainty that's there. Because if I have a patient coming in with an already really persistent case of tendinopathy, it's difficult for me to give them a really precise timeframe. But I at least try to acknowledge that and at least discuss how a plan will look for them and try to outline a kind of stepwise plan.

[00:01:26] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. Tendinopathy will show up regularly in the clinics of many JOSPT Insights listeners.

[00:01:48] In a person-centred care model, of course, it's important to understand the person with tendinopathy, where they're coming from and what they're experiencing. My guest today has been studying patients' experiences of different types of lower limb tendinopathies, and his results might surprise you in just how complex and variable those experiences are. Max Hopes is an osteopath and researcher who's based in Melbourne, Australia.

[00:02:13] He's currently completing his PhD at the University of Technology, Sydney, where he focuses on lower limb tendinopathy. Today, Max shares some of the early results of his PhD work, and we explore what these results mean for your clinical practice. Max Hopes, welcome to JOSPT Insights. Thank you so much. Max, tendinopathy is core business for many listeners to JOSPT Insights.

[00:02:37] We've talked before on the podcast about guidelines and about ways of approaching managing tendinopathy. We might think that we know all there is to know about patients' experiences of tendinopathy, but you're here because maybe there's some aspects that we don't know as much about as we could or should. So, Max, let's start with what the research currently suggests is the general experience of people when they have tendinopathy.

[00:03:02] We conducted this synthesis of qualitative research looking at people's experiences with lower limb tendinopathy. I'm also conducting some primary work in this area, in proximal hamstring tendinopathy specifically. In the evidence synthesis, we essentially broke the experiences into 10 different themes organized hierarchically.

[00:03:27] And broadly, we looked at how tendinopathy impacts the person and then what their experiences with the treatment process were. But as an overview, essentially, experiences with tendinopathy and the impacts of tendinopathy were very mixed and quite variable from person to person. So in some cases, people did find the conditions quite debilitating. In other cases, it was more of a persistent kind of annoyance.

[00:03:54] But quite commonly, symptoms do seem to really drag on in lower limb tendinopathy. And in the studies that we looked at, it wasn't uncommon for patients to have had the symptoms for years, sometimes even decades. So I had a participant in my primary study who had had hamstring tendinopathy for 26 years. So we're talking about pretty chronic conditions in many cases. I think people struggle with the uncertainty that comes with that.

[00:04:23] So one of the things about chronic and persistent pain is it's hard to know where the way out is. And I think people really struggle with that. One participant, for example, who had also had an ACL injury, she said she found that process a lot easier because there was a clear process of rehabilitation that she needed to go through and return to sport. Whereas in the tendinopathy case, she just couldn't see the structure or the plan and how she was going to progress forward.

[00:04:53] Yeah, it's really complex. And I love in your qualitative evidence synthesis, and people will find a link to the synthesis in the show notes, you've depicted the themes from all of this qualitative research in a really accessible way. There's a wonderful graphic in there that people can dive into. I want to talk a bit about our approach as musculoskeletal rehab clinicians. And I think we do a good job at considering what you've labelled impact on activity in tendinopathy.

[00:05:22] And I think we're getting better at considering maybe the psychological impact. And you talked about this frustration and this uncertainty being a real challenge for people. Maybe connected to those two things, the impact on activity and the psychological impact is psychosocial and social impact. We can recognise the social part of the biopsychosocial model. Maybe that's a little bit more challenging or newer for us as rehab clinicians. What does that tend to look like for patients?

[00:05:51] And then with your clinician hat on, how do you think about addressing that more social or maybe psychosocial component with patients? I think there were some interesting themes that we identified in this area. One of the major ones that comes to mind is essentially people's self-identity. In tendinopathy populations, as I've said, it's quite varied, but it does commonly affect active people.

[00:06:16] And we had people in the study who, for example, runners who really identified themselves as runners. And they like to be known kind of in their friendship groups in their community as the person who runs, as the person who's a fast runner or as the person who does lots of running events. And people struggled with having that taken away from them potentially for really prolonged times. And they felt that they kind of lost some of that self-identity.

[00:06:46] There's a participant that comes to mind who mentioned that she liked to be known as the lady who wears high heels. And she had some, I think it was plantar heel pain in her case, and she was unable to wear the high heels. And she said that she really struggled with that. Those kind of impacts on self-identity were quite notable. Maybe a slightly more obvious one would be the social connection that comes often with sporting activities.

[00:07:15] People reported lost friendships. They weren't able to continue to go to sporting clubs or sporting events. And this extended at the time to impacts on families. There was a mother with a young child where she said her daughter, I think it was, was asking her to run after her and chase her and to play with her. And she had to say to her child, we don't do that anymore.

[00:07:38] And you can imagine how that would make a parent feel to not be able to essentially play with their kids in that way anymore in terms of how we address those things. So that is difficult, of course, if I kind of delve into some of the different parts of social impacts that I've mentioned. And so with the identity side of things, I think it's really important that we acknowledge how important these activities are.

[00:08:05] And we don't just give advice of like, okay, you need to completely stop your running. That's just off the menu. You can completely, I think those days are gone for you. So I think we need to try and work with people to help them find load modification and load management strategies to try to keep them going with these activities as much as possible. But obviously still striking that balance of making meaningful changes that are going to assist people to actually recover at the same time.

[00:08:34] And that can be a difficult balance to get right in some cases. But yeah, I think we have to really acknowledge the importance of these activities to people. In some cases, it might be more instead of like being a load reduction, it might be a modification or we have to change the activities slightly or like for a runner. Okay, you can continue to run, but let's stay away from hills. Let's stay away from faster work for now. But you can still get out and continue some running in some form.

[00:09:01] With the connections and the family side of things, I think that can be difficult. But hopefully that ties in with what I've spoken about there in terms of the trying to continue activities just in a slightly different way. One more theme in this area with the social impacts which really stood out in my mind was alienation that some people felt.

[00:09:26] One participant in particular comes to mind who suffered with proximal hamstring tendinopathy. And she felt that hamstring tendinopathy is just not a condition that the general public or certainly her friends and family knew about or understood. Maybe when you compare to other areas like maybe the Achilles tendinopathy, people are a bit more aware of what's going on with that. But she really felt like people just could not understand why she was so limited with this hamstring.

[00:09:54] When she spoke about hamstring, people assumed she just meant it was a muscle strain or some tightness in her hamstring or something. But she was saying how it really impacted her and she really had difficulty explaining this to people. She was a dancer, so she had a dance partner who just could not get their head around why she was having to avoid doing certain moves within the dance class. And then similarly, she encountered a gym trainer who would ask her, how's your hamstring today?

[00:10:23] And she said that she felt quite awkward to say, well, it's just the same as it has been for the past nine years because she felt like people just didn't understand why these conditions can be so chronic at times. That can be a difficult one to address, but I think having that therapeutic alliance and having them feeling like they've got someone who really does understand and hears their story and understands where they're coming from is really important to people. Definitely, Max. Thanks.

[00:11:20] It's really challenging. It's really challenging or something that they might feel that they need to talk about. And if we don't bring it up, it almost becomes like a taboo that, oh, I'm going through something that's strange and it's all me, the patient, as opposed to recognizing that this is something that many people find really challenging with these particularly chronic conditions like tendinopathies.

[00:11:42] As a clinician, I like to be really open in my discussions with people and kind of acknowledge the uncertainty that's there. Because if I have a patient coming in with an already really persistent case of tendinopathy, it's difficult for me to give them a really precise timeframe.

[00:11:58] But I at least try to acknowledge that and at least discuss how a plan will look for them and try to outline a kind of stepwise plan where we're going to go through these different progressions just so they can kind of see the direction that they're moving in a little bit more.

[00:12:15] And that sense of identifying as a person who does something or in the case of the woman who likes to wear the high heels as the person who wears the high heels, I think all of us can identify with if there's some core part of our identity, whether that's related to the physical activity we like to do or something about who we are at work or whatever it is in our life. If that's taken away coupled with the uncertainty of is it ever going to come back, you can imagine that that's really challenging for people.

[00:12:45] A hundred percent, yeah. And it's certainly like maybe I'm in part of my own biases a little bit because I'm talking about runners a lot and I'm a runner myself. But I can imagine having something like this and having that taken away from me would really have an impact. I think people really need that person in their corner, that clinician in their corner and that therapeutic alliance to have someone guiding them through it and someone who they can turn to when they're having these moments of difficulty.

[00:13:10] And that's a nice segue into talking about the treatment element of this and people's experiences with treatment, including the treatment process and the specific treatments that you might use as a clinician to help manage tendinopathy. How does this affect patients and how might those issues show up in the clinic? Yes. So there were some interesting themes that we identified in people's treatment experiences.

[00:13:36] Some of the key themes that we can kind of group together would be what we described in the paper as a knowledge gap. And essentially what we mean by that is patients not having a full understanding of certain aspects of the condition and the management. So people felt quite uninformed or under-informed regarding what the causes and diagnosis actually were. So when people were asked questions like, what do you think has caused this?

[00:14:04] The answers firstly were extremely varied. Some of them were quite logical. Some of them maybe a little bit less logical with the diagnosis. Concerningly, some people were not even quite clear what their diagnosis was despite having been brought into these studies based on having seen professionals and being diagnosed by people to go into the studies. So that's quite concerning in itself.

[00:14:32] I think we have to, as clinicians, one of our roles in general, but certainly with these patients, is to really help people understand how they've reached the point that they're at and really give them that kind of underlying base of knowledge so that they can then move forward. With regard to treatment itself, this was another area where we felt there was maybe a little bit of a lack of education provided to patients.

[00:14:59] When people were asked about treatment, there was a real mix of different types of treatment or different ideas for what patients felt like they needed to do to recover. It felt like the advice they'd received was maybe a little bit mixed and inconsistent. And then sometimes they were just not really given any real advice at all, unfortunately.

[00:15:24] So if we tie all these things together, essentially we're looking at the importance of providing really clear education. And it's something myself as a clinician, I like to really spend a lot of time in that initial consultation with people to really try and help them get their heads around what's going on. I think once they understand that, we know that there's a lot of importance in concepts like self-efficacy.

[00:15:50] And we can really help people to have that greater self-efficacy if they've got that real good base of knowledge. And it's something clinically I feel like I see a lot if I'm managing people with tendinopathy. The ones who I feel like, yeah, they really get this, I feel like they're much more likely to be set up for success.

[00:16:09] Whereas those people who are kind of striding a little bit or they receive conflicting information, that they can be a lot more challenging to kind of get onto that path of recovery sometimes. This is not a groundbreaking thing to say. I still think we need to be doing a little bit better with providing that really extensive education. Another key thing that kind of ties in a little bit with some of those things I've just spoken about would be the importance of therapeutic alliance.

[00:16:38] And this was another major theme that we identified in the paper. So therapeutic alliance, there is research that shows it can impact patient outcomes. And certainly we saw that in this qualitative work where those who felt like they had a good therapeutic alliance with their clinician were very satisfied with their treatment process and seem to describe more successful treatment in general.

[00:17:03] Whereas when therapeutic alliance was not well achieved or patient-centered care was not well delivered by the people, the clinicians that they saw, people found that really frustrating. There was a patient who said they felt it would be easier to send their foot along for their ultrasound scan without them actually there. And I think when you hear quotes like that, that's almost the kind of antithesis of patient-centered care really, isn't it?

[00:17:29] Studies like this help us to understand these impacts better. And by having that better understanding of impact, I think that helps to build the therapeutic alliance because part of therapeutic alliance is empathy. And if we are to be empathetic, then I think we need to really understand the impacts that the condition is having on people. Definitely. I think that's a really important message, Max. I'm glad you get us to that point.

[00:17:56] You mentioned education and you were saying, you know, this is not new or groundbreaking. It should be a core part of what we're doing as clinicians. I think you also made the point that given we keep repeating this message that education is so important and we need to do it, probably suggests that we're maybe not doing it as well as we could or as completely as we could. So what does education look like for you? Is it a leaflet? Is it talking more?

[00:18:23] How do you like to integrate education into the work you do as a clinician? It can be multifaceted. So you mentioned, is it a conversation? Is it leaflets? It's actually in a study, people did seem to appreciate what I would consider as like adjunctive type educational things. So like pamphlets and websites and things like that. People did seem to appreciate those things. But I think the core of it should be a discussion with the clinician.

[00:18:50] My clinical approach, if I have a patient coming in, I try to give them lots of time, which I think people really tend to appreciate. And really just lay those foundations. So explaining what's going on, what the potential causes are in their case, having kind of broken that down in the history. And then talking about the different ways that we can go about the treatment. And this can't be a one size fits all thing.

[00:19:18] I think we have to kind of negotiate a little bit to find that load modification that will try and keep them going with their activities as much as we can, but still making meaningful changes so that they're not just continuing to aggravate their pain. And then we can collaborate and co-design on things like exercise rehabilitation plans as well. We know with tendinopathy that there's different ways we can go about exercise and some of them require more equipment than others.

[00:19:47] Some of them require more time than others. Some people have access to all of those things and maybe we can tap into that. Whereas we have to appreciate some people are really quite time poor, may not have access to fancy equipment and stuff. And we have to factor that into our education and our management planning. One other thing that I think is important, and this maybe ties back in with some of the stuff we've already discussed.

[00:20:12] If we have a real understanding of the impact of the condition, then that may lead to some specific educational interventions. And I'll give you a quick example with this one. I'm quite heavily focused on proximal hamstring tendinopathy at the moment just because I'm doing some other research in that area.

[00:20:33] And when I see patients with hamstring tendinopathy, because we know things like sitting and that kind of compressive load where they have pain in those stretch positions is uncomfortable. I try to really outline that. I've got a bit of a go-to YouTube video that I show people where they can visually kind of see that. Obviously, while providing them with the reassurance that it's not inherently a bad thing and we need to expose back into it over time.

[00:20:59] But trying to help them to understand why some of the things that they're struggling with might be painful for them. And I think there might be some kind of specific educational interventions that we can take in those cases as well. I love the balance. You've got some more generic, you know, we talked about the websites or a lot of people are now using AI and chatting with various AI tools to get information.

[00:21:26] And there's the more generic ways of getting information and sharing information with patients. And then there's, as you say, the tailoring or the making it apply to the person, suit their needs and suit their situation, which is also really important. So balancing those two things sounds like it's key here, Max. Yeah, there should be some general principles that are going to apply to almost all people. And then there's going to be some specific things and every case is going to be a little bit different.

[00:21:55] And we need to make sure that we're kind of tailoring to those aspects as well. The art versus the science of clinical practice, hey? Exactly right. Yeah. Max, speaking of art and science, you've done a lovely job today at sharing where we're at currently with the research evidence and pulling that information together, of course, with the qualitative evidence synthesis you talked about. You alluded to some of the work that's to come in your PhD.

[00:22:20] All of this, as you said, is so crucial to understand what the impact is on the patient. So I want to give you the last word. What's the key message you would like listeners to take with them from today when they're thinking about managing and helping people who are struggling with tendinopathy?

[00:22:39] Firstly, when we're seeing tendinopathy patients, I think spending time in your history to really understand the specific ways that the tendinopathy is actually impacting that person. And then trying to implement some of the strategies that we've discussed already. So really trying to collaborate with that patient. I like to say have a real kind of open negotiation with that patient about which kind of load modifications or load management strategies you're going to put in place.

[00:23:09] So really work with that patient, I think, would be one of the key messages. Don't be afraid to acknowledge some of the uncertainty around the timeframes and just have a really open discussion with patients about that as well. And then obviously patients want to have some sort of clarity and that's why they're coming to see you. So try to outline a logical rehabilitation plan and try to do that in a kind of stepwise manner where possible. So this is our plan today.

[00:23:39] And then give them a little bit of a roadmap where possible for how you're going to return them back to their goal activities. And all the while, I think you have to acknowledge and outline as well with patients that there's always an element of trial and error with this and give them some reassurance that we can tweak the plan as we go at the same time. That's the clinical gold we love on JOSPT Insights. Max Hopes, thanks for joining me today on JOSPT Insights. Thank you so much, Claire. It's been a pleasure. Thank you.

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