[Expert Physio Q&A] Achilles Tendinopathy with Dr Ebonie Rio

This episode with Dr Ebonie Rio is a snippet taken from our Practicals live Q&A sessions. Held monthly, these sessions give Practicals members the chance to ask their pressing questions and get direct answers from our expert presenters.

Learn more about Physio Network’s Practicals here - https://physio.network/practicals-rio1

Dr Ebonie Rio is a world-leading expert in tendinopathies. Ebonie completed her PhD in tendon pain and continues to research this topic at La Trobe University, Melbourne. She also holds a Masters of Sports Physiotherapy degree.

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Transcript

SPEAKER_03 0:01

Welcome to today's

SPEAKER_00 0:23

episode. We are thrilled to bring you an insightful extract from a recent Q&A session with Dr. Ebony Rio, focusing on Achilles tendinopathy assessment. This session is part of her practical series with Physio Network on the assessment and treatment of Achilles tendinopathy. Practical subscribers get exclusive live access to these Q&As where they can ask experts questions and get some answers. Tune in now as we dive into some of the highlights.

SPEAKER_02 0:55

Hello everyone that's joining or watching this at a later stage. My name's Aidan and I help run the Practicals for Physio Network. Today's Q&A is with Ebony Rio who ran the fantastic assessment of Achilles tendinopathy Practical for Physio Network. Ebony, again, thank you for joining us. I'll let you introduce yourself and then we can get into the questions.

SPEAKER_03 1:18

Sure. Hi, everyone. Thanks for joining. So I'm Ebony. I'm a sports physio and I work at the Australian Ballet as a physio and the Victorian Institute of Sport. And I also love to research. So my position is a joint position between the Australian Ballet and La Trobe Sport and Exercise Medicine Research Centre and It's super fun because I reckon everyone that you see is actually an N of one. So you're constantly testing hypotheses. So I do it on a bigger scale, but actually we all do it every single day. So you're all really researchers already, even if you don't think you are, you are. So I'm excited for the chat. Thanks for joining us.

SPEAKER_02 2:01

We'll move straight on to the first question here. Do you ever look at the bent knee calf raise in the assessment, especially if you suspect a mid-portion Achilles tendinopathy?

SPEAKER_03 2:12

The thing about the bent knee calf raise, and it could just be me, but I feel like I don't cue it very well or assess it very well. So if I want to look at a genuine bent knee assessment, I'll do a seated calf raise. So I'll look at standing with a straight leg and I might assess strength with a external load, or I might assess endurance, which is just body weight and the number of reps, but with a straight knee. And then if I'm really interested in bent knee, I'll do seated at 90-90-90 and look at perhaps strength or endurance. I'm not saying it's right or wrong, but it's not something that I do. Is

SPEAKER_02 2:51

there any normative data for reference to know how many single leg raises or hops an asymptomatic patient can perform compared to a tendinopathic patient.

SPEAKER_03 3:01

So we're doing that research at the moment. So we're collecting data on standing endurance, standing isometric strength, seated isometric strength, and looking at sprinters and distance runners and general population because I think it's really important. So to my knowledge, none exist. And critically, I think none exists with really good cuing or really good parameters that you can then take in clinical practice and make sure you're doing the same thing. So to give you an example, if we're going to assess standing calf raise, the great study recently that Brady Green drove and If you get people to just do a calf raise, and we did this in the AFL and AFLW, and then a week later we get them to do it, keeping their knees straight, middle of the ankle joint, second toe, so good alignment and keeping pace and getting full height, people can do about 12 fewer calf raises. So the reason that's important is, one, you want to make sure you're doing it properly. Two, you want to make sure you're doing the same thing each time. But also, if you're looking to research, you want to make sure that the research is informing normative data in a consistent way. So we're trying to do that research right now.

SPEAKER_02 4:23

Yeah, absolutely. I see it personally in the clinic every day. Everyone's a great cheat at a calf raise. So

SPEAKER_03 4:29

many cheats.

SPEAKER_02 4:31

I don't mean to be too nosy with your research and tell us what you're allowed to tell us, but do you have any, I suppose, hypotheses or evolving thoughts around the difference between that symptomatic and non-symptomatic patient?

SPEAKER_03 4:45

There's a couple of ways of answering that. So in general, people with symptoms are clinically can do fewer, but chicken or the egg, can they do fewer because they were predisposed and their capacity wasn't good enough and they got symptoms? So I reckon either way, the best prevention you can offer people with or without symptoms is to teach them a really good quality calf raise for endurance, for strength, seated and standing, just with really good technique. That's going to be your best weapon.

SPEAKER_02 5:19

Yeah, absolutely agree. That's been a really interesting talk there. What could be the cause of getting burning and pulling pain in the posterior calcaneus from calf stretching or with a downward dog position? No tenderness, no pain with walking, running, squats, lunges or hiking.

SPEAKER_03 5:37

So I hope that everyone on the call is thinking... what structure or tissue could drive those symptoms. So your patient's giving you your answer. Actually, Sir William Osler said, if you listen to your patient, they'll tell you what's wrong. If you listen long enough, they'll tell you how to get them better. This is classic. So they've told you that that's neural tissue. So the words that people use when we have neural irritation is burning, sharp pain, stinging, pins and needles, numbness, all those positive and negative neural signs. So your patient's giving you your answer, they're grumpy in their cerebral nerve or they're grumpy in some sort of neural referral into that calcaneus. So you might be looking at, you know, L5-S1 if you think it's like higher up the chain, you might be looking at cerebral nerve if you think it's quite local, but that is screen referral with the downward dog and all that stuff, particularly when you've said, you We don't put a lot of weight in palpation to rule a tendon in because lots of things hurt when you squeeze it. But actually palpation can rule a tendon out. So someone's not tender, it's not their tendon.

UNKNOWN 6:54

Music

SPEAKER_01 6:54

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SPEAKER_02 7:26

The next three questions are from the same viewer. So Phil from Southampton, UK was very

SPEAKER_03 7:32

interested

SPEAKER_02 7:34

in your practical. So the first question, what's the evidence for the importance of nutrition for tendon health, things like vitamin C or zinc?

SPEAKER_03 7:44

I think it's really complex. So most of the nutrition is not directly kind of linked to the tendons. So what I mean by that is it's super tricky to do an intervention where we look at one thing and look at an outcome because we're really complex. So no one's kind of given a lot of vitamin C or a specific kind of nutrition intervention and looked at tendon health or tendon performance or pain. So what we know is that generally, we actually need to have good nutrition for tendon and muscle, but any of our additional supplements have not been shown to be super effective for those three things. So I think if I was giving advice around nutrition or supplements, then we sort of say to people like, you need really good recovery, you need really good nutrition generally, that's very important. But in terms of an additional supplement, there's not strong evidence that anything we ingest has kind of the bioavailability or finds its way to the tendon.

SPEAKER_02 8:53

Yeah, interesting. So I suppose more of a general approach at this stage. At this

SPEAKER_03 8:59

stage, yeah, absolutely. So

SPEAKER_02 9:03

Phil's second question, is a degenerative tendinopathy irreversible?

SPEAKER_03 9:08

Oh, great question. So the area that we would call degenerative is not reversible. So tendon's like super complex and we don't make more normal tendon actually. So if you have an area of degeneration or pathology or load adaptation, like there's lots of names and I feel like actually the naming is very important, but that's another conversation. We adapt and we change the mechanical capacity in the remaining normal tendon. So the area of degenerative tendon is kind of mechanically deaf. So the load doesn't go through it actually. So it's not changeable and it's not changeable with load nor with injections like PRP or shockwave or any of those interventions. And so it's really important to remember that that's therefore the not a clinical outcome. I'm not trying to change that area. I'm trying to improve the pain and function for the person in front of me, even if that never looks any different. And the way I like to think about it is I've got some scars on my skin, but it's like super functional. It just looks different.

SPEAKER_02 10:21

Yeah, fair enough. Well, I think you touched on it on the practical as well. So it's positive and reassuring for the patient that I suppose you can always make new tendons Just on that note, a personal question. I was just wondering if from a physiological point of view, is there a tendon healing cycle or a timeframe that it generally takes to form and lay down your tendon?

SPEAKER_03 10:45

Yeah, it's not the same as muscle where we have like a tear and proliferation and inflammation and scarring. It's quite a different process actually. So we have this sort of adaptation, and it depends on the tendon. So during puberty, we lay down our tendon. So if you play a lot of sport as an adolescent and you have changes in your patellar tendon, you'll lay down more tendon and you'll have a big fat tendon and that's super But our other tendons are a little bit different. So it varies between tendon, but the tendon healing or trying to normalize the tendon is different compared to, I have to say, muscle and some of our other connective tissues. So the timeframes for improving pain and function is what's important. So changing pathology or changing imaging is not an outcome for any of our tendons, whether it's supraspinatus, tippost, lute med, patellar tendon. So don't serially image it because they might look the same over time. In fact, they probably will look the same over time. You won't change it.

SPEAKER_02 11:56

Yeah, fair enough. And I suppose there's plenty of studies out there to support that remark in that pathology or the structure doesn't always dictate your function.

SPEAKER_03 12:07

That's true. And that's true in low back pain and OA and tendon. Like, we're not different. All right.

SPEAKER_02 12:13

I think we might call it there. Thank you again, Vinnie. We'll see you in about a month's time for the Q&A following the Management Practical.

SPEAKER_00 12:22

Awesome. Thanks, everyone.

SPEAKER_02 12:24

Pleasure.

SPEAKER_00 12:26

And that's a wrap. We hope you found Dr. Ebony Rio's insights valuable. Remember, this was just a brief segment from a comprehensive 45-minute Q&A. Practical subscribers have exclusive access to live sessions with world-leading experts like Dr. Rio, where they can join live and submit questions in advance. If you'd like to be a part of these incredible monthly live Q&As and access our growing library of practicals, claim your seven-day free trial by visiting the link in the show notes or heading to Thanks for tuning in and we'll see you next time.