Welcome back to the Healing Pain Podcast with Dr. Ebonie Rio
At the time of this podcast recording it’s summer in the United States and no doubt many people are out enjoying all sorts of activities including sports, exercise and hopefully running around playing with kids. I know that some of those people might also be sitting it out or perhaps taking it a bit easy because they have tendon pain and despite all sorts of treatment, they have yet to find a solution. If you have any kind of tendinitis or tendinopathy in your knee, ankles, shoulder, elbow, my next guest may have the answer to solving your tendon pain once and for all. Joining me today is Dr. Ebonie Rio. She has a Master’s Degree in Physiotherapy and completed her PhD in Neuroscience where she studied in-depthly the health and pathology of tendon as well as how the central nervous system and motor control might change in individuals with tendinopathy. She’s a practicing clinician as well as a research fellow at the La Trobe Sport and Exercise Medicine Research Centre at La Trobe University in Melbourne, Australia.
Tendons, Pain And The Brain; What’s New And What Does It Mean For My Clinical Practice? with Dr. Ebonie Rio
Dr. Rio, welcome to the Healing Pain Podcast.
Thank you very much for having me.
I’m excited you’re here and I know a lot of people in my tribe are going to be excited too because originally you were supposed to be on one of my summits a year or two ago and I’ve got a lot of emails saying, “What happened to the tendon topic?” I kept promising people, “I promise she’s going to be back.” I’m excited that you’re here to share this important information.
Thank you so much for persisting. I confess to messing up the time zone for our interview several times. That’s all on me. Thanks for making time today.
That’s okay. People can obviously hear your wonderful, beautiful accent. You’re calling from Melbourne, Australia. You have a very interesting piece, obviously it’s based in neuroscience but you studied the health or the pathology of tendons. Why did tendons specifically? There are so many aspects of pain that we can research into but how did you get interested in tendons?
I was lucky enough to spend time as a clinician up at the Australian Institute of Sport under Craig Purdam who many people would know is a tendon guru and also have a long-standing great relationship with Professor Jill Cook who I did my honors with. Both of them are wonderful tendon nerds. I was always surrounded by people that were passionate about tendons. When I was working mainly with basketball and track and field, it was the tendon injury and tendon pain that just gave us so much trouble. A bone would break, we would respect the healing time of the bone we’d have a period of unloading and reloading. They didn’t give us too much trouble; whereas people that had tendon pain, it would persist for years, we try and keep them going, it would flare up. We had very few strategies for getting them better. We had people with persistent and recurrent symptoms. They provided my biggest challenge. I think in research, that drives my research questions, the people that you couldn’t help or didn’t do as well or couldn’t get better. Tendon pain is challenging and that’s why I love it.
You also worked with ballet dancers as well for a period of time, correct?
Yes, I worked at The Australian Ballet and was lucky enough to keep a relationship with them. I was there last Friday, actually.
You and I have something in common because I worked with dancers for about three years. I worked with Broadway dancers here in New York City and some of the ballet companies. I can tell you, working with tendon injuries and dancers is really challenging because oftentimes they don’t modify or can’t modify or can only modify their activities so much. That must be another interesting population where you can put your great research to work.
One of our most highly loaded are athletes and unloading to them is really a concept that they’re not comfortable with. They like to stay very highly loaded. A modification for them is still incredibly high load. You negotiate what you can. Some of the research that we’ve done around reducing pain and specifically right before someone performs has been incredibly useful for them to be able to keep them going in season or in competition.
On the podcast I like to talk a lot about busting some beliefs and some myths. What are some of the myths that either clinicians or the public has around the cause of tendon pain, shall we say?
Probably a historical one is using terms like tendinitis. When people hear tendinitis, they think inflammation and they think, “Oh my goodness, my tendon is inflamed. I have to rest. I should anti-inflammatories.” It really conjures up a very passive approach to their injury and their pain. What we now know is that a tendon doesn’t heal through that classic inflammatory process the way a muscle does. We don’t have the same response. For the clinician and for the patient, my first message would be, don’t use words like tendinitis, use words like tendinopathy because then people really get on board with needing an active approach to their treatment and that’s critical. The first myth I’d like to bust is that it’s not a true inflammatory condition and the pain isn’t from the cells there that might be associated with the inflammation. They’re more about communication. The cells are there to talk and know what’s going on. The first thing is we need to get moving. If we use terms like tendinitis, people think they should sit on a couch with an ice pack and we know that that’s ineffective.
It’s fascinating because I’m thinking of all the millions of prescriptions right now that are being written that say epicondylitis, rotator cuff tendinitis, patellar tendinitis. Oftentimes the patient sees that first before they get to the physio.
It’s critical that the language from every clinician that that person has an interaction with is really positive. Tendinitis is one of those things that you think it’s not that harmful but that underlying premise really evokes a response in people of how they think they need to manage their pain.
How is the healing process for a tendon different than the traditional healing process, the traditional phases of inflammation that we all learn about in school, the basics?
Tendons are really stubborn. Once they have some response or pathology in them and it might just be a load appropriate change that the tendon has these changes just because you’ve loaded for a long period of time. Once the tendon changes, we know that it’s really hard to reverse that matrix once it gets to a certain point. The tendon isn’t capable of making new collagen. Collagen is very, very hard to make. The tendon and the human is amazing, and it adapts. This wonderful research by Sean Docking that shows that if you have an area of tendon pathology, the tendon thickens up. What you have is this amazing response and sufficient aligned structure that’s capable of taking weight. I call it good tendon. You have enough good tendon. The body goes, “We’re making tendons really hard. I won’t bother trying to heal that part. I’ll adapt and respond.” Other tissues adapt and respond. It’s just that in tendonland, we’re a little bit slow to catch on. It was really exciting and game-changing research for us because we no longer have to try and heal the pathological area because the body really has done the hardwork. It’s our job to then just rehabilitate the whole person.
So often, I think people have images in their minds of a pathological tendon or something that could be wrong with their tendon. Those images are things like a rope being frayed where these strands are a horse’s tail and it looks like a mess and has no tensile strength to it. Is that true with tendinopathy?
Another great question and this is another great myth to bust. A lot of the pictures that we draw for our patients or the words that described on the imaging reports like fraying and tearing and even degeneration. It sounds awful. What people think is, “Oh my goodness, I better sit on the couch. I’m vulnerable.” Again, what Sean’s research has shown us is that if you see something on your MRI or your ultrasound that says that the tendon is thicker so you have an increase in AP diameter, what we say to people is, “Fantastic, well done. Your body is amazing. Your tendon is amazing. You’ve done a great job of adapting and now it’s our job to help calm down your pain and just rehabilitate you back to your goals and what you want to be able to do.”
Tendon tearing is an interesting one. We’re actually no better at flipping a coin at picking whether or not it’s a tear or tendinopathy on imaging. There are few studies that actually back that up now. Even saying to someone that you have a tear is very, very difficult to quantify. But if someone thinks their tendon is torn, they’re not going to move. Again, our language is really critical, but we also know that tendons are so strong. If you have a muscle and a tendon and a bone and you pull on it, the first thing to go is the muscle tendon junction and that’s a muscle strain. Next, we see the bone tendon junction because it’s an interface, then the bone, then the tendon. Normal tendon is so strong and doesn’t tear so what you can have is letting go in an area of pathology and for the most part we would manage that like a tendinopathy, it wouldn’t change our management unless someone had a complete rupture.
We’ve done good work at telling people when they fracture a bone that a fractured bone actually heals better or more solid than before. We have yet to do that with tendons so this is a great topic to talk about. You mentioned the word vulnerable, are there populations based on their activity or genetics that are more vulnerable to tendon pathology?
There are. The first thing is if you’re a really good athlete, you have a really good spring. Genetically, you’re a better athlete and you have some of the genetic predisposition to make you a bit more predisposed to get tendinopathy. You’re also more likely to then play sport because you’re better at it. It’s an interaction as well. We know that our really good athletes are our most vulnerable athletes, the ones that use their tendons like springs: our Achilles are good sprinters, patellar tendons are good jumpers, all of those aspects. In terms of who’s vulnerable to rupture, I always get asked these, we know very little about this group because for the most part they’re people that don’t have pain. The people that usually rupture a tendon have no symptoms. We know they have underlying pathology. They’ve gone through some process in their body and then done something like stepped off a curve, they put a big load on their tendon that the tendon is unaccustomed to. Because they haven’t pain, we have never seen them in clinical practice. We know very little about this group. The group that rupture and are vulnerable, we don’t know very much about. The people that get tendon pain, and sometimes this is reassuring the athletes, you’re the good athletes.
As we talk about it, it makes me think that the entire world have danced in gymnastics, which we know receive more tendon injuries in are more susceptible because they’re actually better at their sport and their tendons are “more springy in essence,” which is interesting because most people look at those population and say, “It’s your actual sport that causes the injury.” You’re saying maybe there’s a play between the two; a play between your genetics and the sport. I guess, we’ll never really know what came first, the chicken or the egg, in some instances. In talking to practitioners, what are the key questions to ask a patient during the initial evaluation or the in-take when they have tendon pain?
The first question that’s critical is where is your pain? That’s because tendon pain actually remains incredibly localized. You can point to it with one finger. It doesn’t move or spread regardless of the length of time in symptoms. That’s a real hallmark feature. It’s really critical. It’s not localized pain to palpate or to poke, it’s pain that remains localized when you ask that tendon to act like a spring. The second key feature is that you have increasing pain that remains localized with increasing tendon load. The best way to explain that is the Achilles tendon. You can have two presentations in the Achilles tendon. You can have mid-substance where we’ll allow two fingers because they tend to pinch. They don’t move up and down so they just pinch. Remember in the university how we learned tendon pain can be three to four centimeters above the calcaneus. That’s just because different people have different length of Achilles that really is very localized.
The other presentation is the insertion with a point with one finger. What we might ask someone to do is a double leg calf raise and ask them how much their pain is and where their pain is followed by a single leg calf raise, double leg jumps, single leg hops, we can do big hops and then forward hopping is maximal Achilles tendon load. You may not take every person through that whole assessment depending on their function. Your little old lady, you’re not going to get to jump and hop. What you would do is you would ask them where their pain is and you would see an increase in tendon pain that remain very, very localized as you took them through that protocol, through that assessment. The two key clinical questions then are, where is your pain and what aggravates your pain? The aggravating factors for tendons are anything that ask that tendon to be a spring. For the patellar tendon it’s jumping, it’s fast change of direction like tennis, all that really quick stuff, which is why we say patellar tendon pain in volleyball players and basketball players but not lawn bowls because it’s not fast.
What is a lawn bowl?
It’s a game you play when you’re older and you bowl the ball really slowly and try and hit something up the other end. It’s a retiree game. Those were verbal examples, sorry.
That’s okay. I love learning new things on this podcast, which is one of the reasons why I do it. I learn something new almost every day. The lower extremity makes perfect sense to most people because we’re talking about bounding recoil type activities. People are going to say, “I have rotator cuff tendinitis or tendinopathy.” How do you examine that and try to use the same principles?
Joe, I should have warned you that I stay away from the rotator cuff. These amazing clinicians and researchers, Jeremy Louis, that spend their whole life on the shoulder and they’re absolutely the experts. These tendons in the rotator cuff that appear to act like springs, especially when you’re throwing and loading up. That silly little supraspinatus that doesn’t appear to be energy storage, it appears to be more positional and seems to be quite different. What’s going on around there is definitely up for debate through different people in the world. The tendons in the upper limb that seem to be springs that we would treat with our kind of tendon approach are maybe the lateral elbows. They remain fairly localized and aggravated by loading activities. The long head of biceps, you can get both compression as you go into shoulder extension and there’s also a sheath on the outside so you can get irritation of the sheath as well, similar to how you came with the Achilles where it can be compressed against the heel bone and you can do sliding and gliding activities, like riding a bike, that irritate the sheath.
We’ve covered most parts of the body. If a physio is listening or a physical therapist is listening, how should they approach tendon care in their rehab program?
The first thing would be, get your diagnosis right. Make sure you’re looking at someone that has the incredibly localized pain with tendon load. Then you would want to find out, what changed? Tendons hate change. It’s a real feature in someone’s history that they changed something, they increased their load in some way, they changed their footwear, they started running up hills. You want to know what was different for this tendon because that’s when the tendon sticks its antenna up and says, “I’m not happy.” You want to know where their pain is and what aggravates it, but critically what’s changed. Then obviously, all the other features of subjective assessment that you would do for any patient about finding out about irritability and all of those characteristics. Once you’ve established your diagnosis, then you’ve got two really critical pillars of care. One is around exercise, that’s vital. Other is around education. Both of those things are crucial and you won’t get anywhere unless you address both.
If we start with exercise, we take people through a program that is very tailored. No two people would get the same program, and that’s because people have different start points and different goals. That’s what rehabilitation is. What’s your current capacity? What do you want to be able to do? Jill Cook and Sean Docking have a wonderful editorial on this that talks about current capacity and goals and how to get there. Because tendons hate change, you need to take people up in very small steps because they get very stubborn and if you take a big step, their antenna goes up and they get cranky. If we’re considering exercise, the first thing that we would tend to start with is an isometric or a static hold. That’s because we have research that shows that it reduces people’s pain substantially and for quite a period of time.
Similar to what we’re talking about before in ballet, is we can actually get someone to do these isometrics right before they perform or right before they go into class, or the football player, right before they go out on to the field. The way we ask that question was, what’s also the effect on their muscle strength? You can’t just reduce someone’s pain and not know the effect on function. If you completely fatigue their muscle and they get another injury, the coach and the athlete aren’t happy with you anyway even if you help their tendon pain. The re-switch was very practical. How can we use it? We might start with an isometric exercise.
We would then progress to concentric and ascentric using the muscle through range. These first two phases aren’t hard for a tendon. Remember, the tendon acts like a spring. That’s what’s hard for a tendon. Stage one and stage two, that’s heavy in terms of weight, is hard for the muscle. This is really about a muscle building program where you’re dealing with the muscle deficits and the day conditioning. You need to get them strength for the other side, for the rest of the kinetic chain so you can spread the load. All of those things you’re doing in stage one and stage two. Stage three is where you want to make them springy again. You just ask the tendon to just do a little bit of energy storage. It might be something like lunging in on one leg but not changing directions; running up instead of breaking with the patellar tendon and stopping. Stage four would be the in and the out; the energy storage and the release and adding in all the critical features of their sport; how many jumps they need to be able to do, all the change of direction. You’re really making it individual for them.
Your little old lady that just wants to walk around a golf course, you’re not going to get her hopping and jumping and landing and doing stage four work. You’re going to really tailor to what she needs. Within that you need to make sure they have sufficient endurance and also cope with compression if they need it. Compression is where the tendon wraps around a bone. The Achilles down at the heel is a good one to think about. The person that needs to get into dorsiflexion, like how dancers when they plié, they need to be very tolerant to compression down at that insertion.
The education part of it is around busting the myths for them?
Absolutely. David Butler talks about this beautifully, and Laura Mer. During the subjective assessment, I make a little mark of anything that they say, how they think about their tendon, how they describe it, anything that anyone has told them about the imaging, just what their general understanding is and especially if they have any fear and then what we will spend quite a bit of time doing. Jill Cook and I like to consult together. We’ll spend quite a bit of time talking through, “See your ultrasound,” and they’ve written all increase in AP diameter, we’re like, “Fantastic, increase in AP diameter.” You can take the facts. You can take the information and turn it around to something that is not only positive but also factual. That’s a critical part of the education.
The other thing that’s good for people to understand is that your capacity only ever just exceeds the loads you put on it. The best way to think about that then is if I drop my load because I’ve got pain or I’ve been told to rest or I’ve had some passive intervention where they then said, “You need to have a couple of waits off.” All that happens is I’ll drop my capacity, and that’s a great way thinking about why our passive treatments don’t work, because they don’t actually change our capacity. The only way to change our capacity is to slowly build up our load a slow pace that the tendons are happy with so that you can gradually build them back to their activity.
I love the framework too. The framework is the proper diagnosis, figuring out what has changed and then, you’re working through exercise, isometrics, then isotonics through a full range of motion and then progressing on to more challenging activities up to sports specific-type activities. Of course, not forgetting about the importance of education and core beliefs when you were with any patient who has any type of persistent pain. I think it’s a great framework for any type of pain syndrome. I want to look at the exercise piece for a minute though because isometrics are interesting. Isometrics wind up in a lot of physician protocols for certain things. Oftentimes they are sub maximal isometrics, or you’ll even see on a prescription, “very gentle isometrics, pain-free isometrics.” Do we know yet what the secret sauce is in an isometric exercise and why does that help alleviate someone’s pain?
We know some of the ingredients in the secret sauce. I’ll tell you what we know and I’ll tell you what we don’t know and what we’re really interested in. We started piloting the isometric protocol for the studies we’ve done on the back of the clinical reverse engineering of Jill and Craig. I think this is genius. If you are a tendon, acting like a spring is the most challenging thing. But complete rest is no good to us because all you do is drop your capacity. They need some load. A static load was what they started playing around with. When we were looking at the piloting of doing the study, it was like, “These people are getting immediate pain relief.” We knew clinically it would help them and help them in the next day, but they were getting instant pain relief. Then we decided to look at that. We piloted time under tension and we piloted how heavy the load needed to be. I spent 18 months doing very, very, very heavy loads, knotting 100%. People can’t hold that for very long effectively, so they do a very short contraction, three or five seconds if you’re lucky. That wasn’t effective for analgesia. That didn’t help pain. It didn’t hurt them because remember you’re not asking them to act like a spring, but they didn’t see any benefit.
Then I tried a much lower level, so 5% and 10% and 20% and 30% for a very long period of time which people can hold. The other reason why this was a critical thing to pilot is the first study was actually done in a lab. When we’re doing the non-invasive brain simulation, they’ll do an MVC and they’ll also hold a contraction for 10% or 20% while you’re doing the brain testing. I also needed to make sure that my brain testing wasn’t what was giving them analgesia. Part of the 18 months was if you’re doing an MVC, does that change your pain? It’s actually not about my isometric intervention. Or if I’m doing brain testing, is that what’s changed? We needed to look at every little component individually so that we could say, “Is it the intervention?”
I played around with different combinations of time under tension and load. If you don’t hold it long enough or if it’s not heavy enough, it wasn’t effective for the tendon. We made it back down somewhere in the middle for five lots of 45 seconds at 70% of their maximum voluntary contraction. That’s where we started. We chose a two-minute rest in between to be really conservative. We want a complete muscle recovery. No central fatigue because remember those were really clinical question, what exercise could you do right before you go on stage or right before you go on the field? We measured not only their pain reduction in a pain provocation test but we measured their cortical inhibition, the drive down from the brain. We also measured their strength. We found that we released this excess inhibition that they have that’s associated with their pain, that would reduce their pain substantially and they we’re actually 19% stronger. After doing a very heavy isometric load, they were 19% stronger.
The other clinical question for me is you’re just warming them up, could you have done anything? Does it matter? That’s what we compare to the isotonic protocol. We also had a protocol that we randomized to do the same time under tension, so they’ll match and the same RPE. The only difference is, are you holding it static or are you moving it in the patellar tendon? The secret ingredients in our special sauce, we know that load is critical. We know that time under tension is critical. Clinically, we look for some sort of balance between the two. This by all means is not a recipe. We have someone with gluteus medius, tendinopathy or bursitis. We do this with everyone. We look at what they can do. If they can’t hold 5 by 45, we might modify either the load or the time to get what we need. The other critical thing is people talk about pain-free isometrics. This won’t be painful for your tendons. What happens is the first one people might go, “I can feel it a little bit.” The second or third is fine. We use this in differential diagnosis, immediately following they’re substantially better, much, much better.
It’s almost like a little neurohack. I’ve heard very few people actually try to hack the nervous system. Hacking sounds like it’s almost something you do down the back alley. But things like this really start to open doors into the nervous system. I personally think that we have probably an innate wisdom and intelligence in our body and we just have to figure out how to leverage that. From a neuroscience’s perspective, which is who you are, what do you think that you’re almost replicating there in a way? Is it taking us back to almost like a fight or flight response where there’s such a load and a contraction that the nervous system is sending that inhibition because pain would not serve you? Or do we even have any idea exactly what potentially could be happening?
Tendon pain appears to be protective and not dissimilar from other pain. There’s something that happens when someone does a heavy isometric that must change something associated with that specific contraction because some of the people in this study had bilateral patellar tendon pain and they only got relief on the side that they loaded. Critically, this is not just the exercise induced hypoalgesia where you’re riding a bike and you just generally feel better. It’s something quite specific and it was compared against the isotonic. What it’s actually doing? We have no idea that was associated with changing with the inhibition, but what’s changed at a tendon muscle, corticospinal and central level. We’re not sure. I’m going to steal that neurohack, I love that.
The next part of rehab and exercise is trying to change the other component of motor drive. You can think of the drive to the muscle and clinicians understand this, but this is how I explain it to my patients. You can think of muscle control like the accelerator and the brake of a car. You’ve got your accelerator or your excitability and you’ve your inhibition or your brake. Everything you do is a balance between those. People with patellar tendon pain had changes to both their accelerator and their brake. In fact, they’ll both stuck on. They’re both working maximally, which was different to people that had other types of knee pain. We had controlled jumping athletes with no pain or pathology and they had a normal response that you see in the literature. Then we had people with more diffused interior knee pain. You might call it patellar femoral pain, for this purpose we just said diffused pain. We didn’t give it a name. What they had was a normal excitability curve. Their accelerator behaved normally. What our patellar tendons had was a completely different response. I could zap your brain and tell you whether or not you had local pain or patellar tendon pain or diffused pain. I found that fascinating.
We published this research with Laura Merrin. This to our knowledge was the first time we had really shown a difference in that excitability based on maybe the nociceptive driver as best we know. Clinically, there are different populations and the brain seems to think so as well. Then if we have a change in that accelerator and a change in that break, what strategies do we have in terms of exercise to address those? Is our rehabilitation adequately addressing those? Is that why the pain is so persistent because we haven’t actually addressed any of these even if we have done a reasonable job at the tendon and muscle level? That’s the next thing we looked at doing.
What is the next thing that you think we should really look into that we haven’t looked into but sounds like that would be the one place to go with that? To really figure out what types of exercise protocols work for what types of tendinopathy?
We know that exercise is the cornerstone of management. It’s going to be the best way to get tendon adaptation, muscle and kinetic chain. We know that generally, it’s fantastic for our brain. If we can really hone in on our motor cortex, what strategies do we have that are exercise-based that can actually modify our excitability? There are a couple of different ways in the neuroscience literature to do that. A really super simple one is timing your movement to a metronome. If you externally pace an exercise like a leg extension, not only do you guarantee your time under tension and all of the physiological things that you’re after. What you actually do is fire up all these wonderful connections between your auditory cortex and your motor cortex and your frontal lobe because you’re really planning and concentrating. It’s the opposite of sitting in the gym and having the music blare at you or watching the cute guy do a dead lift or thinking about what you’re going to have for dinner. It’s mindfulness while you’re doing strength training. It’s not just playing a metronome and zoning out.
We’re in the process of making an app. What you do is do exactly what it says and watch the cues and listen to the cues, trying to really pick up those, make the strength training more of a skill because that’s what the research in neuroscience shows. If you just do strength training without some of these strategies, if you do a self-paced strength training, that you will get stronger because you change your muscle but you actually don’t change that motor drive. That’s really a simple one.
The metronome obviously brings in your frontal cortex, so you work on the cognition part of it. When you’re working with patients on education, you probably work on the limbic systems, you work on the emotional, the core beliefs part. Of course, exercise is your somatic sensory cortex. You’re using a lot of real estate in your brain which is incredible. Sign me up for the tendon nerd club. It’s a great topic. I could go on and I’m sure there are going to be lots of great feedback from this podcast. Where can everyone find more information about you, your research, and all the great things that you’re up to?
La Trobe Sport and Exercise Medicine Research Centre, we have blog. It’s a wonderful resource. People can access it through the La Trobe website. They can click on my publications, Jill Cook’s, Sean Dockings and we all contribute to the blog where you might have Jill’s ten things of what not to do if you’ve got tendon pain or Christian Barton offers things up on patellar femoral pain. It’s a great resource for lots of different injuries through the La Trobe website. I’m no longer on Twitter anymore but Jill’s on Twitter so you can always hit people up through Twitter as well.
I want to thank Dr. Ebonie Rio for being on the Healing Pain Podcast sharing all her wisdom on tendinopathy and of course how to heal and live with less pain. Of course, with every podcast please share this out with your friends and family. It’s great information and I’m sure you know someone who struggle with some type of tendon problem in some part of their body who’s looking forward to leading a pain-free and active life. I want to thank Ebonie for being on the Healing Pain Podcast. We’ll see everyone next week.
About Dr. Ebonie Rio
Joining me today is Dr. Ebonie Rio who has a masters in physiotherapy and completed her PhD looking at tendon pain, how the CNS and motor control might change in individuals with tendinopathy.
She is both a practicing clinician as well as a research fellow at the La Trobe Sport and Exercise Medicine Research Centre at La Trobe University in Melbourne, Australia.
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