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Tendinopathy of the patellar and Achilles were the focus of Sean Docking's Phd with Jill Cook

Tendons focus of Queensland breakfast

29 April 2016

The Queensland Branch Breakfast will feature Sean Docking, of La Trobe Sport and Exercise Medicine Research Centre, discussing his research on the clinical barriers to tendinopathy rehabilitation. Sean spoke with Emma Breheny ahead of his appearance.

What’s your background in tendinopathy research?
After studying health science, I went on to do a PhD with Jill Cook, primarily on structure and imaging in tendinopathy. The PhD looked at questions like, how does a normal tendon respond to load, how does a normal tendon become abnormal, and, most importantly for clinicians, once that tendon becomes pathological, what might be limiting rehabilitation from a structural point of view.

What did your PhD reveal about the structure of tendinopathy?
My PhD primarily used an imaging modality called ultrasound tissue characterisation (UTC), which not only produces a three-dimensional ultrasound image of the tendon but also allows us to quantify structure, including how much normal tendon there is versus how much disorganised. A study we did with 96 patients compared pathological patellar and Achilles tendons to structurally normal tendons, looking at the mean cross-sectional area or the volume of normal tendon structure in both classifications. What we found was completely contradictory to the clinical knowledge at the time. The pathological tendons actually had more normal tendon structure than a structurally normal tendon. There’s a strong relationship between the amount of disorganisation, and the thickness and size of the tendon. We suggested that this thickening is likely to be an adaptive response to ensure the tendon has enough normal structure to tolerate load. This led to the analogy developed by Craig Purdam of ‘treat the doughnut and not the hole’.

This goes some way to explaining why you can see asymptomatic pathological tendons, and points to a limited relationship between improvements in tendon structure and clinical improvements. Therefore, we shouldn’t be targeting our interventions towards remodelling the structure.

What direction should interventions be taking in light of this?
Apart from addressing the immediate pain, we need to address function. This is the ‘next frontier’ for all of us I suppose: understanding what functional deficits and lower limb kinetic chain difference need to be addressed. It’s a very difficult thing to measure well, because people present with all different kinds of deficits, but it’s where we want to go.

How widely used is the ultrasound tissue characterisation method?
It’s primarily used for research at the moment, with its clinical use currently limited. It’s very helpful from a differential diagnosis perspective and to reassure patients that they have enough of that normal ‘doughnut’ to load.

What other research will inform your presentation?
Recently, I’ve presented with Jill Cook, Craig Purdam and Ebonie Rio on a revisiting of the continuum of tendinopathy that Jill and Craig put forward in their British Journal of Sports Medicine paper of 2009. This presentation examines what new evidence we have in support of the continuum, how clinicians think about the continuum now and what needs to be revisited. However, one of the main things is looking at this relationship between structure, pain and function. I’m really passionate about figuring out what critical factors stop patients getting better and back to pain-free function, because we now know it’s not structure. A lot of researchers in Queensland, like Bill Vicenzino’s group, are doing work in this area.

To deal with the immediate problem of pain, Ebonie Rio’s work has highlighted the isometrics exercise, shown by a randomised control trial to be useful in-season. As Ebonie discusses, reducing someone’s pain with exercise immediately gives you fantastic buy-in and it means they’re more positive about the rehab.

 

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