Using Exercise to Fix Pain - Guest Dr. Ebonie Rio on Tendinopathy and Understanding The Patient Journey
Short Summary
Working toward excellence with Olympic athletes and performing artists
What tendons are, how they function, and how they’re injured
Why the term tendinopathy is replacing tendonitis, and why that change matters
Why the best evidence for managing tendon pain often points to exercise
The key steps that help tendon pain improve - and why the order of those steps matters in a physical therapy protocol
New understandings of tendons viewed on imaging
Why different tissues respond differently to exercise — and why exercise speed matters for tendons
How exercise speed determines which tissue you load
Dr. Rio’s research on isometrics for in-season athletes
Reducing pain without reducing power
The brain and nervous system in rehab
The role of compression and muscle strength in tendon health and injury
The difference between physical training and physical therapy
What “protocols” are in therapy and training
Using cueing and communication to alter load distribution in training
Pain interpretation within physical therapy protocols
The relationship factor: why the relationship between people affects outcomes
Four essential questions to ask your physical therapist
Disclaimer
The information and content provided by Mind Body Literacy and in this video and podcast is general information and is intended for educational purposes only. Individual situations vary. This content is not intended as, nor should it be used as a substitute for, professional medical or psychological advice, diagnosis or treatment. No guarantee or warranties are made with respect to the accuracy, applicability, fitness, or completeness of the content.
Episode and Guest Introduction
One of the underlying ideas of this podcast is is how learning and new information, they change.
How we see things, what we understand, and what we think we know today, well, it might change tomorrow.
Whether you're a coach, professional athlete, a teacher, a clinician, a performing artist, or just somebody who's trying to figure out about your own body.
And that's why I'm excited to share today's episode, a look at how physical therapy has quietly evolved over the past few decades.
Science, movement arts, and clinical practice are constantly evolving.
And my next guest's work is a perfect example.
When I first came across her research in twenty fifteen, I was thinking mostly about movement, muscle, and fascia. But her work opened my eyes to the fact that tendons are a whole different story.
How they respond to load, how pain fits into that picture, and that there are clear evidence based steps to help tendons recover.
Even when we recorded this episode last year, I was still learning new things, like how the speed of exercise changes whether a tendon actually receives load.
When she returned from the twenty twenty four Summer Olympics in Paris, I had the chance to sit down with Dr. Ebonie Rio. Ebonie is a sport and exercise medicine physiotherapist and one of the leading researchers in tendon health and pain science.
She's a passionate teacher and presents at national and international conferences, guest lectures at universities on tendon health, foot and ankle rehab and pain science, and supervises Masters and PhD students.
She's worked with everyone from Olympic athletes to everyday people who just want to move without pain.
Her career has taken her across the globe. The Paris Olympics, Vancouver Winter Games, Singapore Youth Olympics, London Paralympics, and two Commonwealth Games.
Beyond sports she spent eighteen months as physiotherapist for Disney's The Lion King during its Melbourne and Shanghai tours. And she serves on the Scientific Advisory Committee for Little Big Steps, a charity helping children stay active through illness and recovery.
Her approach also reflects something I value deeply: honesty about what we do and don't know, and helping people understand their bodies and empowering them to be proactive, Ebonie’s work sits at the intersection of science, movement, and care.
Driven by one mission: to help people move better, recover smarter, and live healthier.
I'm really glad to share this conversation with you. Here's Dr. Ebonie Rio.
Transcript
Nathan Schechter: So welcome, everybody. It is my pleasure today to welcome doctor Ebonie Rio. And, Ebonie, as we're recording this, it's the summer of 2024, and you have just come back, as I understand, from the Olympics in Paris this summer. And I wanted to ask you about that because you've done really super interesting things. Like, you've worked with athletes. You've worked with artists. You've worked with ballet companies.
You've worked with football. I wanted to ask you if that's American or European or Australian. You know?
But you've you've seen a lot of athletes and artists, and I'm just curious what kinda led you to working in those places and also what you learned from it, like, you observed, what you experienced?
I'm really interested to hear about that.
Dr. Ebonie Rio: Well, first of all, thank you for having me. I'm really excited to talk to you, and that's a great first question.
I think across all of those different groups, whether it's, you know, dancers or the different types of athletes, they share that common drive and that passion and that motivation. And they're also driven to be better at their craft, and that's really special to be part of.
So even though there's so much variety in the groups that you talked about, they have so so much commonality.
And I think it's that drive to push their physical and mental capacity to the edge and beyond is so inspiring, and that's probably the part that I love, you know, contributing to or or trying to be part of.
Nathan Schechter: Yeah. No. That is super, super inspiring and also very palpable to be around.
I remember that from - I'd worked in big organizations, and I went to boxing gyms and saw some of the most motivated people you would ever see because: nobody cared if you practiced, nobody cared if you showed, either you did it or you didn't.
And so people so badly wanted to learn. People would push themselves, and I was like, this is the highest level of motivation sometimes that you can see is with athletes or with performers.
It really is something you can observe and feel.
So I totally understand that.
You've also done a lot of your work with understanding tendon dysfunction, and I know that we'll have some folks listening who, you know, this may not be their field or they may not be that heavily into it.
So I just wanted to start off with a few definitions and the basics because my mother, back in the day, didn't know the difference between a tendon and a ligament.
So could you start us off by just saying what is a tendon and what does it do and that?
Dr. Ebonie Rio: Yeah. Absolutely. And it is really great to define the terms because there are so many words, and people use them often interchangeably, especially in the media and, you know, when we're googling. So I think terminology is really important.
So a tendon attaches our muscles to the bone, but it's not just a passive structure that kind of just, that's all it does.
It actually, in our lower limb, really acts like a spring.
So it makes our movement more efficient, but it's also what makes our athletes and our dancers really good.
So they have really good springs. They have really good tendons.
So in our lower limb, our tendons mainly act as a spring to store and release energy.
So whenever you're running and jumping, you're really using that Achilles tendon, but we need to use that tendon throughout our whole life.
If you step off a curb or walk downstairs, you actually store and release a little bit of energy in your Achilles. So our tendons are so important throughout our whole life. So not just for our high level athletes and dancers, but for all of us, they're really important.
And that's why we can see injuries in a really broad spectrum of people.
Now when the tendon is injured or we have pain or it's dysfunctional, we call that tendinopathy.
And we specifically use that term because it's not an inflammatory condition, so we don't want to use words like tendonitis.
Because if we say to someone that you have tendonitis, 1) it's inaccurate, but 2), it'll conjure up really passive approaches to their treatment. So they'll think they need to rest. They think they'll need ice. They think they'll need anti inflammatory medication, and, actually, none of those are effective.
So the best evidence for managing tendon pain is exercise.
And so tendinopathy is a really important term to help people navigate and understand the underlying kind of function of what's going on.
Now a ligament goes from bone to bone.
So you've got ligaments in your ankles, and you've got ligaments in your knees.
All of your joints have ligaments and capsules, and they're quite passive. So they're really important in terms of stability and structure, but they're not as cool as tendons because tendons actually help us function at a really high level.
But I'm pretty biased, Nathan.
Nathan Schechter: Yes. So the tendons are the cool kids in school.
And this is something that I wanted to ask you.
I think it's changed over even the course of our lifetime. Right?
It used to be, I remember, I think, when I was younger, like, if the elbow was bothering you, you had the tennis elbow or the ankle or the knee, you called it tendonitis. Right?
You said, oh, it's tendonitis.
And I think to what your point was, you just think in your mind, like, well, if I burn myself on the stove, they tell me to put my hand under cold water or put ice on it.
So if this is inflamed and hurting me, I guess I should put ice on it, and maybe I should rest. Like, that seems to be the smart thing that I would do just naturally, and that has really shifted.
And I think one of the things that you're pointing out here is that there's a difference between an “itis”, an “osis”, and an “opathy”, that these words and so could you tell us a little bit more about, like, what does somebody mean when they're a clinician and they say, well, you have tendinosis? Or they say, oh, this is tendinopathy.
Or somebody says, well, look. I have this picture, and it looks thicker, and, you know, I'm worried about that.
Can you tell us a little bit about that?
Dr. Ebonie Rio: There's actually so many great questions in there.
So the first thing I'll say is that tendinopathy is the term that we should be using.
So tendinopathy is the term that's been agreed in an international consensus project that we ran. We included clinician experts, research experts. We included patients.
So the term tendinopathy is the one that we should use. We shouldn't use tendonitis at all. It's actually not a clinical condition.
You're exactly right. It's what we used to call it.
And that was because that reflected our understanding of it. And it's okay that our understanding changes over time, but we need to make sure that our language also changes over time so that our patients don't have those instinctual kind of expectations about treatment. Otherwise, there'll be a real mismatch between what you're saying and what they think needs to be done.
And just to highlight how important words are, there's a fantastic systematic review, and they looked at manipulating terms and the impact on people's understanding of what they needed to do.
So if you tell people that they have a fracture, 56% of people think that they need a plaster cast. If you report the same injury as a crack in the bone, 13% percent of people think they need a plaster cast. So it's the same injury, but I've changed the words, and people's underlying understanding what they need to do is different.
So tendinopathy is the same. If we're not being really careful with our words and we're allowing people to just sort of say tendinitis and then I'm giving you an exercise program, deep down, you're thinking, but doesn't she know my tendon's inflamed?
So we have to take that as an education opportunity to say to people, yeah, we used to think that the fluid and the swelling that you see on imaging, we used to think that was inflammation. We now know that it's water because some of the pathology, some of the changes are that the tendon actually draws in water. So the tendon gets thicker, but it's not inflammatory in the way that when you burn yourself or you sprain an ankle, you sprain a ligament, or you pull a muscle.
It's a very different process.
So tendinopathy is the term that should be used.
Tendinosis refers specifically to the pathology. So what that means is if you have tendon under a microscope, you're allowed to use tendinosis, but otherwise, it's not a helpful clinical term. It's you know, even the terms that are used on imaging reports aren't that consistent, so that can be really tricky for people.
But there's one more thing that you said that I just wanna take the opportunity to teach people. We used to worry about a thickened tendon being bad. We actually know that that's highly adapted.
So Dr. Sean Docking did some research in the achilles and the patella and showed that if you have changes in your tendon, you have as much normal tendon or more than someone with a completely normal tendon. So the increase in thickness is an adaptation. It allows me to have enough load bearing tissue to do my rehab program and to do really well.
So an increase in ____ diameter or anterior posterior diameter or an increase in thickness, we should be celebrating that, not fearing it.
Nathan Schechter: Yeah. So it sounds like, just as with many things, people are relating to sort of what they're experiencing, and that first sense is, uh-oh, you know, something's wrong.
Or even if something's not wrong, it's like when people try to use nutrition.
Am I hungry?
Or what's the sensation that people are trying to put words to (to match their) experiences?
And the way that they do that can determine a lot of things.
It can determine, well, if I say I'm hungry, I'm gonna eat.
If I say I'm just stressed, maybe I don't eat. You know?
And so if I say this is a tendonitis, then I conjure up an explanation, which is, oh, inflammation, oh, therefore ice, oh, therefore whatever.
That's taking me down the wrong road, and I've kind of made a connection between my emotional state and my cognitive decision making with a word that's kind of heading me towards a treatment decision that may not be in my best interests because what we've learned has changed.
Whereas if I say tendinopathy, now I have something that suggests to me, hey.
First of all, don't worry so much about changes in thickness or seeing water or the state of the collagen.
If the collagen's going from 3 to 1 or 1 to 3, like, don't worry about that stuff. That's not so much what's important.
If you stick to what we've kind of defined as you just described for us and you use this term, that's gonna put you on a good middle path where we can start to address the issue and actually bring back function, and actually address pain.
And this is so using that word is more helpful for many of those reasons.
Am I hearing you right?
Dr. Ebonie Rio: You've nailed it. Perfect.
Nathan Schechter: Great. Alright.
And, so I also wanted to ask you then a little bit more specifically about isometrics because I know that was some of your work.
It's also how I first became aware of you. I think you'd written a paper in 2014, and then I'd seen something, I think, in Switzerland you had presented in 2016. And this was on patellar tendinopathy, and you were talking about how isometrics are good and helpful, and also address pain to some extent.
And that also, when I read one of your papers, it was very interesting because it seems obvious in some ways. And not only obvious, but intuitive for people, but I sort of thought: “Oh, you're saying exercise can produce pain relief.” You know?
And that can be done properly and improperly, but one of the first things I ever saw when I was teaching yoga was people would be titrated out of their PT, and they would show up to try to use a group fitness class as physical therapy.
And you'd have to say: “Yeah. You know, maybe that's not the, maybe we need to to redirect you a little over …” but it was the right impulse. Right?
Like, it was the right impulse of I want to use movement in some way to help myself, and I wanna be proactive about that.
Like, right impulse, maybe needing to go to a different place.
And so you had done this study, I think, which was about an eighteen month study, and just if our terms are gonna be defined again, so help me if I'm here, but so concentric, eccentric, right, isotonic for people who don't know at home, and then I take my arm and squeeze really, really, really hard. No change here.
You can feel, you know, the squeezing.
So now we have our isometric. Right?
And so you did this study, you know, isotonic versus isometric. You control for a lot of the same things: 1) time under tension, which is basically how long you're having the muscle under tension, 2) the rate of perceived exertion, 3) the rest periods, and a lot of other things.
But can you tell us a little bit about that and kind of what protocol you came up with and and a little bit about how you got into that and what you observed?
Dr. Ebonie Rio: Yeah. Sure.
So I think a good place to start is to understand what a tendon does.
We talked about a tendon storing and releasing energy.
So for it to be high tendon load or high tensile load, it's gotta be fast.
Tendons are about rate of loading.
So the converse of that, Nathan, is that anything slow or static is easy for a tendon. So that's really how the research started, you know, that basic sort of first principles.
So Craig and Jill Cook had been, you know, using it clinically, and, you know, I was involved with them. And, essentially, the reason I designed the study is I just thought we're warming up the tendon. I honestly didn't think it would matter what we did.
And so to answer the question as to whether or not the load type was important, that's why I tried to control all the other variables.
So, same time under tension, all of the things that you described.
And, essentially, the first study that we did was a laboratory based proof of concept study, so very tightly controlled, you know, nothing like the real world with a Biodex. And for people that aren't familiar with the Biodex, it's a isokinetic dynamometer, but what it is is it's completely fixed.
So if you're doing an isometric, you can't move it.
So it's it's a completely static immovable load.
But what you can also do is provide feedback for people so that you know they're producing the force that you want.
So the first study that we did, we compared the two types, and we found that people had pain relief from both, but a greater immediate pain relief from the isometrics, and that was associated with a change in their inhibition.
So inhibition is kinda like the brake in your brain.
So when you do a movement, it's a balance between your excitability or your accelerator and your inhibition or your brake.
And what the isometrics were associated with was a lifting of the brake.
So people were actually stronger after doing it.
They could actually access more of their kind of motor neuron pool. So even though they've done, you know, five lots of 45 seconds at 70%, it's quite hard.
They're actually 18% stronger, which meant that clinically, it was quite a safe thing to do before, you know, training and playing, which is really important to know if we're gonna try and use it in the real world.
We then took that study into the real world and did it as a randomized controlled trial in season, and we used a leg extension.
And what we found with a leg extension machine that you have to kind of hold at a certain angle was that we didn't have as profound immediate impact. So people could like, it's quite a different isometric.
Does that make sense?
So we found that both isometrics and isotronics helped people over four weeks.
Again, people had a more profound immediate effect with isometrics, but the key clinical message is that they're both really safe in season.
And that's important because the research should have been completed before that, but in season management showed that if you add eccentrics in, people did worse.
So, clinically, if we're managing athletes at the Olympic games or we're managing, you know, dances during a performance season, we didn't have great research supporting exercise that was safe and effective.
And you're exactly right.
You know, coupled with our terminology, we want people to understand that exercise is actually our long term strategy.
So introducing it really early and when it's associated with pain relief or analgesia is quite motivating as well. It's also something that people can do themselves, which I think builds self efficacy, and it's drug free.
And so, you know, obviously, as a physio, I'm very biased towards exercise unashamedly, but I think it provides us with a way in.
You know, we have someone with tendinopathy. We don't need to wait. We can immediately start with safe, slow, or static load and then progress them back into, whatever they want to do.
Nathan Schechter: Yeah.
So it sounds like you're saying you took folks, you hook them up to a machine. This machine has the ability to actually measure the force that somebody's putting out so you can make sure it's commensurate for each participant.
They then go through putting out isometric force.
You measure it at a certain level, and that was the first stage of this.
And that you then see, hey, this has a helpful effect in terms of reducing pain.
And, you know, a lot of folks don't know that athletes work, have kind of an off season training and an on season training.
Obviously, when they're doing the full schedule of the ballet or they're, doing the full games and competitions, the trainers, the physios, the people who work with them have to adapt around the loads and the conditions that are changing.
Most people never see this in their day to day lives, so they they don't even know what those schedules feel like.
But there's often different demands at different times, and so what somebody like yourself has to look at is, okay, well, I might be able to do this with somebody on an off season, but on season, they gotta get right back on the field, or they gotta get right right back on the dance floor.
So if I have them in the physio clinic and they're contracting or they're lifting or they're loading, if I do x with them, will they be able to perform at the same level and compete at a very high level, or am I making them worse?
And their coach is gonna turn around and go, what the heck are you doing? You know?
And so you then look at this, you test with the leg extension, you go:
“Hey, this is not only awesome just in general for folks, but when you're working with these athletes and these high performers who have these different demands at different times, we can actually work with them at the time of maximum load, maximum demand when they have to perform at their best.
And guess what? If we use isometrics, not only do we reduce pain, but they still perform at as high a level.
And guess what? They actually can even perform and put out a little bit more power because this funky thing that happens inside of us where our brain has these wires which go down our spinal cord, and there's this little interneuron down there. And if you wrap it around with another little neuron and it acts like a dampener, you know, we can actually get that to relax a little bit and get a little more power output.
So it's good for high performance. It's good for pain relief.
We can give it to them. They can do it quick. And so this looks like a really useful intervention”
And that was sort of the path that you saw.
And then you can also say, like, hey, and even if you're just at home and you're not competing at the Olympics or dancing Giselle, you can still use this because, it's helpful, it's self efficacious, you don't need a drug for it, it's cheap. You can learn this stuff.
Am I hearing you right?
Dr. Ebonie Rio: You've nailed it. Perfect. Perfect summary.
Nathan Schechter: And let me ask you something else because I know you say often when you're talking about tendons that, like, fast compressive force.
And just again to define our terms, so, you know, a really good thing that I got in training was they would teach you the difference between compression where bone hits bone. Right?
So, if you're a yoga teacher, don't try to adjust somebody if two bones have come together because bones don't move in the same way tissue moves.
But then if it's just tight tissue, tissue has a little bit of give.
So these places and you use the example often of dorsiflexion where your foot, you know, is like this rather than plantar flexion where it's like that.
But if you have a compression where some joint is compressed bone to bone and then you move quickly - so you're running and you're sprinting and you turn on the field - that tendons don't like that.
They don't like fast movement.
The okay. Just to correct myself, what you said before was tendons need loading, and they need a lot of loading, and they need to experience that.
But an injured tendon in somebody who is recovering and has had acute injury, that might not be the place that you want to start putting them into compression and quick, fast speed.
Am I saying that all right?
Please correct me if I got anything wrong or misled anybody there.
Dr. Ebonie Rio: No. Spot on.
So it's just where you don't want to start.
So it might be where you need to end up, you know, if that's what our tendons are designed to do.
But you're right. If you've got a grumpy tendon, what you would take away, Nathan, is the fast stuff, and you take away the compression.
So compression for a tendon is where the tendon is squashed against a bone.
So you're right for the Achilles as it comes down and you go into dorsiflexion or you put your knee forward of your ankle, your tendon is compressed against the back of your heel.
That's why if people have insertional Achilles problems, they don't like being in bare feet because they get into compression sooner. They prefer to be in a shoe with a heel. They don't like doing calf raises off a step. They can actually be quite provoked with yoga because a lot of downward dog is in a lot of dorsiflexed positions.
If you've got hamstring tendinopathy bending forward can be a problem. Sitting can be a problem. So that compression is something we would take out early.
But what we want to do is work out what people want to get back to and help expose their tendon to some really gradual adaptation and progression to get them back to the faster work and to get them back to the compression because it's you know, compressing our tendons is part of life.
And so you're spot on.
It's a good strategy to take out early and then work out how we help people get back into it. So it isn't you know, you can never stretch your Achilles ever again, but maybe in the short term, that's gonna help you to avoid. Right.
Nathan Schechter: I think that's something also that people struggle sometimes to understand, that what you're saying and what I'm hearing is, look, tendons are meant to bounce and jump and do hopscotch and, you know, run and twist and do basketball and go up for the big layup and come crashing back down. Like, we're built to do that.
We're not made out of sugar.
But, if you have acute injury or trauma, now you're in a slightly different category for a moment.
And, again, of course, tendons are different and are treated in different ways. The patellar tendon is different than the Achilles tendon.
We don't treat everything the same.
But just talking in generalities, if we've hurt or tore the Achilles, like, we don't then say, hey, go do a lot of jumping and plyometrics right after the day after you tore it. That's probably not great advice.
So we set that aside, and then we have a protocol.
Often, people don't even understand protocols just for building muscle, let alone protocols for physio, and they don't understand the difference between training and physio, which I try to tell people:
injured tissue = physio
healthy tissue = trainer.
But there are steps to the process.
And so you say, Okay. Look. If it's a physio issue and it's gotta go through the stages and let's say it's the Achilles, we're going to take away the strain on it in the compression where the tendon is getting pushed against the bone. We can give you, like, a high shoe to support you.
We're going to try to let things calm down a little bit.
Yes. We do want to get you back to jumping and twisting, and we are going to reintroduce that.
But before we do that, we gotta do some other steps in the recipe, and some of those steps, as I've heard you explain, have to do with creating enough strength.
And you've even said, like, so I want the person to be able to do so many split squatsk or whatever, rear elevated foot squats or one legged work, you know, and I want people to be able to do, this much, you know, calf raises, bent or straight legged, and so I have this step I have to get people through.
You show me that you're okay, you're performing, Your pain isn't going through the roof, and then we can talk about moving you on to the next step.
Am I hearing that right?
Dr. Ebonie Rio: Yeah. Absolutely.
And the way we want to teach people and empower people to go through those steps is to give them really clear goals as to what you'd like them to be able to do in that strength phase.
And what we do is we teach people to listen to their tendon 24 hours after the load.
So your tendon will speak to you, often not at the time.
So what I mean by that is tendons are a bit tricky. They can warm up.
So for some people, if they're very sore at the start of an exercise, they might pull out and do under load, do too little.
Some people will warm up and do far too much.
So what we don't want people to do is base their rehabilitation or their progression on how they feel in the moment because it's misleading.
What we wanna do is say, okay. We're gonna get you to listen to your tendon tomorrow.
And tomorrow morning, your Achilles, your morning stiffness will tell us if it's the same or better than the day before.
Your tendon was happy with what you did. It may not be zero, but that's okay. If your pain is low and stable and similar to yesterday or better, that's a happy tendon.
If your pain has spiked, then whatever we did the day before is what we've gotta modify going forward next time, remembering that we actually don't need to rest.
So if I flare you a little bit, I'm still gonna get you to do your slow calf raises because that's very safe for a tendon. It's not fast, and it's out of compression.
So anything slow or static is safe for the tendon.
So you keep doing your calf raises.
And then the next time I get you to do something that's a bit faster, I'd modify it in some way. You know, do a few fewer reps and then see how you are the day after.
Nathan Schechter: I want to ask you about that because I think it's another thing people don't really understand.
You said about slow. Look. It's slow. It's controlled. We're building strength.
I'm feeling good here working with you in this way.
I don't think people really understand what speed does, how speed increases force.
And you even had some pictures, just simple charts in some of your presentations showing, like, the different level of force, you know, that can be there in different movements.
That when you start to run, when you start to jump, that the force goes up exponentially.
And, I don't even know how good our data is on this.
Maybe you can tell me, but I know that we are still trying to learn how to measure inside of joints, which is very difficult for ethical reasons and a lot of other things.
And that if you look back to articles in the nineties, they'll say things like, yeah, you know, we had a study in the 1940s, and it told us that it's, like, 3 times your body weight with running and up to 16 times your body weight with jumping and 3 to 5 times your body weight with compressive forces when you're standing. And they'll give you these numbers.
But I don't think that people really understand the difference - that when you start to run or when you jump and come down, there is force.
And even - because one of the things that I see a lot and have seen a lot - people will exercise in a way that is very poor with form, and they'll do it quickly. And you want to say to people, you know, the idea of exercising at speed with poor form, having force going in an angle into a joint, that's just not a great idea.
And then you say that, and people are like, well, you know, you're just a purist. And you you're like, no.
Like, there's a real thing happening there, and you're using a machine. And would you take your car and whack it on the side with a wrench?
I don't even think people always understand that when you go through a car part you know, if you're in a car accident, god forbid, but it's force that's hurting you. It's not even - if you were immune to glass and metal and somehow you had a body that wasn't hurt by that - it's the force.
So can you talk a little bit about how speed interjects force and why when you jump or you run, suddenly it's not the same as when you're just walking, that something has actually changed that you can't see.
Can you say a little bit about that?
Because you said, well, I like it because it's slow, and they're building strength and it's controlled.
Can you talk about that a bit for people?
Dr. Ebonie Rio: Absolutely.
So if everyone at home downloads a metronome, just download a free metronome onto your phone, and then you can re-listen back to this recording, and you can try this for yourself.
So if you set your metronome pace to anything below 120 beats per minute, the main tissue that you're loading, Nathan, is muscle.
Now you're also loading bone because your muscle pulls on the bone, but that's a good thing. The muscle pulling on the bone conditions the bone for when we do walk and run. It actually keeps our bones really healthy and really safe.
Nathan Schechter: You're talking if somebody's walking.
When you say 120 beats - you mean walking to the metronome?
Is that what you're talking about?
Dr. Ebonie Rio: Anything. Even a calf raise.
Nathan Schechter: Jumping?
Dr. Ebonie Rio: Any. Any loading
Nathan Schechter: Any movement. Any movement over 120 - versus under 120.
Dr. Ebonie Rio Spot on.
So under a hundred and twenty, even if you're doing a pulse, or a calf raise - whatever exercise you're doing, you're mainly loading your muscle tissue.
The reason why the muscle pulls on the bone is a good thing is then when you do run, your bones are conditioned to take that load, and that's good. That helps protect us from bone stress injury.
So when we get a bone stress injury, it's actually not just about impact loading. It's about how hard the muscle's pulling on the bone.
So strength training is really, really important for bone health.
Okay. If you're loading between 120 beats per minute and 150, you're starting to load some of the more connective tissue elements.
So, you know, the scaffolding and the fascia that your muscle connects into.
And we need to load that tissue as well.
That's really important.
When you load above 150 beats per minute - for example, if I get you to hop, your natural hopping cadence is about 2.2 hertz. It's about 150 beats per minute - you’re loading tendon.
So what happens - as you increase the speed of movement - is your muscle can't contract quick enough.
So if Usain Bolt runs a hundred meters,his gastroc is basically isometric, and it's his Achilles tendon that is acting like a spring. If he had to contract his muscle to run a hundred meters, it'd take him about, I don't know, six minutes. I made that up, but he'd be very slow.
So as you get faster, the best tissue we have to transmit the load quickly to the bone to affect our joint movement and to make our movement more efficient and faster is tendon.
So that's how we load our tissues differently through our rate of loading.
So when we're talking about our slow movement, I'm talking about, for example, a single leg calf raise where you might go one second up, one second down, 60 beats per minute. Slow. Below 120.
Nathan Schechter: And that’s loading muscle, not tendon.
Dr. Ebonie Rio: Muscle. I'm not loading tendon.
And that's why your calf raise exercises and your gym based exercises don't put any high load through your tendon because they're too slow.
But then we need to press you back into those faster things.
And the way I might do that is I might get you walking up and down stairs, and I might increase the pace on the metronome so that you start doing it faster and faster and faster until you start jogging and loading your tendon.
And that's how I might progress you through a rehabilitation.
Nathan Schechter: So if I took a barbell and I put it on a squat rack, and I locked it in place, and I pushed up as hard as I can, I'm only going to ever affect, no matter how hard I go, it's just muscle. I'll never activate tendon.
Dr. Ebonie Rio: Spot on. Yep.
Nathan Schechter: Interesting. Interesting. So you start off by strengthening the muscles, making that the first order of priority because they need to be strong enough before you can go back to rehabilitating the tendon. Is that what I'm hearing you say?
Dr. Ebonie Rio: Yeah. So predominantly, the main part - the main stay of strength is to affect the muscles. So if you've got a really strong, competent muscle, it gives your tendon something to pull on.
Whereas if you if your muscle isn't good enough, it's gonna it's gonna give out, and you won't even be able to use your tendon effectively.
Nathan Schechter: And say somebody's made it They graduated. You say, okay. Good enough. You're doing your stuff. Your calf raises look good, and you're doing your split squats, and I'm happy with that. What’s the next step that you would then, you know, take somebody into?
Dr. Ebonie Rio: So just say someone wanted to get back to running. After they've got, you know, good calf strength and endurance, what I might do is take them through progressive stairs.
So if I increase that rate of loading on the stairs, so if I go up to 130, you know, 150, by the time I'm getting up to 150 and I'm jogging, I'm starting to load my tendon.
And then what I can do is give you some stair running, listen to the tendon the next day and say, yeah. I was happy with what we did.
Great.
The next time we do that session, I'm gonna add some time or I'm gonna add some speed.
And I'll just progress that rate of loading back to whatever you want to do. If you want to run a hundred meters or if you want to run, you know, 150 kilometers a week, I just push your rehab to whatever you wanted to be able to do.
Nathan Schechter: So you have your 24 hour test.
You look if pain over time is going down or staying around the same but not getting worse.
If so, you change a variable and you say, let's go more distance. Let's go faster. Something that will increase the load on the tendon progressively, the same you would do for muscle, but, in this case, for tendon.
Is that pretty much the game there?
Dr. Ebonie Rio: Perfect. Yep. That's pretty much the game.
Nathan Schechter: Before I ask you another question, anything else you wanted to say about anything we've talked about so far? Anything I missed or forgot to ask you?
Dr. Ebonie Rio: No. I don't think so. I think that's pretty clear.
Nathan Schechter: So I wanted to ask you something a little bit different because I know that you also have an interest in plasticity and the mind and the brain, and, certainly, that comes up a lot around pain and stuff like that. And so I had a few questions on that.
One I just wanted to ask was, do you think that we can control where load goes by directing it with our mind?
That when we're actually involved in an exercise that we can use our mind to say, you know what? I'm gonna target the tendon, or you know what? I'm gonna target the muscle, or I'm gonna, you know, somehow use my mind.
Because when you're, even if you're doing a leg press, you have a lot of decisions about where to put your feet, about how hard to press, what part of your foot are you pressing with, where are your knees, are you engaging subtly, or you know?
And, of course, this can be different for different people. Some people can't feel their hamstrings. Some people are acrobats and dancers.
But, for people with good body sense, they have a high degree of control, and I know that one of the things about, like, ground reaction force is, we're different than a box. Right?
If you put a box on a table, it has ground reaction force, but it just sits there. How we hit the ground, the angle, how our muscles respond to the ground to get that force back changes things.
So I'm thinking, okay. Well, if we're squatting or we're pushing or whatever, can we use our mind to purposefully shift things around?
What's your thought on that?
And then we're getting out of - I just say we're kind of - that's why I asked you before - kind of moving from firm territory to less firm territory.
But because I deal with the art and the science, and focus on the creative and artistic side as well as the scientific side, I like to visit both territories because one of the things that I talk with people about is, hey. you know, information is meant for you to ask questions.
It's meant for you to integrate. It's meant for you to explore and say, I wonder if this could work.
Hey. What about that?
Which we don't necessarily have answers for.
I wouldn't necessarily do in a clinical setting, but in a more creative or sporting or artistic setting, we certainly would do.
So I wanted to ask you some of those types of questions as well.
Dr. Ebonie Rio: I think we can, and I think everyone listening to this would have experience of that where you can manipulate in real time either someone's cueing you or what you're thinking about or what you're visualizing.
And I think I've learned a lot by working with dancers because I think they had this unbelievable ability to take on so much information and so many cues about how they're moving and make subtle differences, you know, by what they're thinking or what muscles they feel they're engaging.
And, you know, a movement to your eye might look the same, but to a trained artistic ballet staff they'll they'll pick out the most finite details.
So that was a very long winded way of saying, yes. I think we can consciously manipulate how we create a movement.
And I think those degrees of freedom and the way we do things are fantastic.
And, you know, I'll play around with someone's foot position or cueing on a leg press, for example, if they've got patellofemoral joint pain.
If you get them to, you know, push more through their heel and kind of lift their toes off, you can reduce some of the pain they feel through the front of the knee.
So you can definitely alter things for movement quality, for pain relief, for lots of different things, even just just awareness, as you say, for people to to move their bodies and to feel their bodies in a different way.
Nathan Schechter: Yeah. And and from this sort of perspective that we're looking at things from in this view, do you think we could say in some ways that people learn and unlearn pain?
That you've done a lot of work with tendon and brain change and how tendon pain can disrupt sort of that balance between excitation and inhibition when the nerves are sending the messages and they have a little breaker circuit for a very easy term, but an interneuron.
Right?
So an interneuron can make some decisions about what gets through to Grand Central and what doesn't.
And so then you have this thing which you've done, which is maybe you could say a little bit about tendon neuroplastic training. Right?
And so the coordination of movement with tempo.
Right?
We use tempo in weightlifting. But, also, you're using tempo in a different way.
So now we're using hearing.
So there is a learning process that's going on. And I'm just curious about your thoughts about that.
Dr. Ebonie Rio: Yeah. So I was lucky enough to have professor Lorimer Mosley as one of my PhD supervisors, and he talks a bit about or a lot about, pain having like a neurotag.
So what that means is when a certain combination of neurons in your brain light up at the same time, you have a neurotag for knee pain, for Achilles pain.
You have a neurotag for smelling fresh bread.
So what that means is you get information from your body.
So in the case of fresh bread you've got what you can see visually. You've got your nose. But what happens is that sensory information arrives at your brain, and your brain has to make sense of it.
And so it says, okay. Have we been here before? What information can I draw on in my memory?
You know, what's my visual information? What's my, what's all the sensation I have? But have I seen this before? Was it safe?
Was it dangerous?
And in the case of fresh bread, your brain goes, oh, yeah. That's fresh bread. So your nose doesn't know it's fresh bread. It's your brain that tells you that it's fresh bread.
Pain's the same.
You've got nociception and information from your body, you know, about not just your nociception, but your joint position sense, your muscle tension.
You've got all that sensory information going up via your spinal cord - as you say - this modulation of the spinal cord - as to what gets through to grand central.
Up at grand central, your brain goes, have I seen this before?
Oh, yeah. That's my Achilles pain.
So can you change that?
Yeah. Definitely.
Can you, you know, learn and unlearn pain? You can.
You know, plasticity and adaptation and maladaptation are, you know, one of the incredible things about us as humans.
So yep. Absolutely.
Nathan Schechter: Yeah. And that process of adaptation, you know, I mean, that is something you know, that is a very curious part of all the different physical pursuits.
The thing I wanted to circle back to was, you had said earlier, when we talked about definitions and how important they are, and how they - and I think - because we can get lost sometimes in the science of it.
And for people's experience, it's often just: I'm hurt.
Or I'm worried.
Or, you know?
It's much more simple.
And, also, it's an interpretation. It's also I think that's where the anxiety comes from, which is what's wrong?
I don't know, and I can't see it.
Right?
Like, I cut myself. I go, okay. I cut myself. I see it.
But these internal things, I can't see, and, and that can affect us.
Right?
How we explain what's happening can affect our decision making.
And, you know, I wanted to just use an example that I had come across once where somebody had actually come in and was backing off some exercise just because they said, “well, it hurts a little or I have this you know?”
And then they came back another time and, fine, everything's good and raring to go. I'm like, what changed?
It was an allergy to food.
But because it produced sensation in the joint, they interpreted the sensation as if it were injury.
It wasn't injury. It was a reaction. You know?
But that's the experience for people, which is I have a feeling, and I don't know - especially you'll see this in kids. Right?
Like, I have a stomachache, and it makes me super worried. It's just a stomachache, but I don't know anything about this.
And so now I'm worried because I have this inner sensation. I'm trying to put a label on it. I don't understand it.
And that can, I think, not only drive the kinds of things that we're talking about with words, but also does that not play a role in treatment adherence too?
Like, if I feel like my ankle is injured and even though the person tells me it's tendinopathy and I should load it, I might be kinda hesitant to do that because you know what? As much as you tell me that, it hurts.
So what are your thoughts around that?
Dr. Ebonie Rio: I think you brought up one of the most important points about how we frame and allocate time and our conscious decision making about structuring our time with our patient.
So as someone's talking, I will make little e flags.
So that's a quote from David Butler who's a fantastic pain scientist.
So an e flag is an education flag.
So while you're talking, I'm not gonna interrupt, but Nathan talked about he's worried that it hurts.
Okay. So that's an e flag. That's an opportunity for me to do some education.
He talked about he's worried about the imaging and how it looks.
Okay?
So as you're talking, I'm just making all these little notes that I'm gonna circle back to.
Because if I don't take the time to address inaccurate language or fear of movement or fear of pain, if I don't take the time, I could write the world's best exercise program, and you're not on board. And I don't blame you. Because inherently, your experience is to trust yourself. And so while I can build therapeutic alliance, I'm better off spending my time building my therapeutic alliance in teaching you how to trust your body, when to listen.
So your body's gonna give you great information.
But what I wanna do is say to you, “Nathan, your tendon is a bit sneaky. And when we're doing some exercise in the gym, you might feel it a little bit. I wanna reassure you that that's okay. I want you to tell me how your tendon felt the next day.
So I'm going to give you permission to ignore it at some points, but I'm going to ask you to listen to it at some points.
And so it's helping people filter the noise.
But I think if we don't take the time in framing our treatment and giving that much time to what you've said, the words you've used, and your understanding, then that will affect adherence.
You know, I'm always interested if I see someone for a second opinion if they haven't done their exercises because I think that is unbelievably rich information.
If they haven't done it, why?
Did they not understand the value?
Did it make them worse?
Because, actually, not everything in the posterior ankle is Achilles tendinopathy, and some conditions are worse with a calf raise.
So if you come back and say to me, I tried Ebonie. They gave me calf raises. They absolutely made my pain worse. That is clinically so valuable to know.
So as soon as someone isn't adherent, fantastic.
Let’s chase that.
But when you're structuring your time, don't underestimate the value of listening to the person.
Don't underestimate the value of meeting them at their story.
That's another Dave Butler quote and making sure that you're, you know, taking the time to validate them and empower them. And then your exercise is a mainstay for tenonopathy.
And the last thing would be things like manual therapy.
I'm not saying manual therapy doesn't have a value, particularly if it's allowing someone to do their exercises. But if you come straight in and I get you on the bed and I rub your calf and then quickly check your exercises at the end, then what I'm telling you is that I don't value the exercises.
So even if you don't say it out loud, that's what you're gonna hear as well that I don't value, which means you think, oh, how important are they? Like, she barely looked at them. So making sure our conscious and our unconscious messaging is really clear.
Nathan Schechter: Yeah. I see a lot of that where people are struggling with the execution because they didn't have time in the session.
And so they don't have the experience with exercise, so it's very hard for them to figure out how to even execute it correctly even if they want.
The other thing I want to just enlarge on there slightly was because this is a conversation that happens even outside of physiotherapy, you know, where for lack of a better word, the holding environment.
And I wanted to circle back to your experience with athletes because with athletes there's this thing with coaching where, you know, it's not just about the information.
Coaches have very different styles, and the relationship between the coach and the coachee really makes a big difference in terms of what gets absorbed and what gets done.
And I've talked about this with a lot of our high level performers and stuff.
And I've experienced it myself when I'm being coached by high level folks.
Some people are very intellectual and cerebral, and they'll explain all the whys and the wherefores.
Some people are, let's just get down to business and do it.
People have different personalities, and they come together in different ways, but that actually affects the outcome even if they're not injured, just high performance or just regular performance or achieving the skill, and it can affect other things.
So it's like, yeah, it's great to have all the correct information.
And if you’re a computer or AI, well, you just hook them up and download it, and it'll all take care of itself and run the program.
People don't operate like that.
People are worried. People have to get to know other people.
People have feelings about people's personalities.
And so this environment in which the either, you know, physical therapist or coach and the athlete, that actually is a part of the result you get.
And I'm wondering if you can talk because, yes, it can be education.
Right? It can be education flags.
It can be telling people the right things.
It can be taking time.
It can be listening.
That's all true, but there's this other X factor of: who are these two humans and how do they gel when they're trying to solve a problem together?
Can you say something about that, or have you seen that in any of the ballet companies, Olympics, or things like that?
Can you talk a little bit about that?
Because I have talked about that with a lot of the other high level folks, and I'm just curious about your thoughts.
Dr. Ebonie Rio: Yeah. I love that.
And you're right. It's the X factor that people have tried to give different names to, like therapeutic alliance, but there probably isn't one term that captures it all. Right?
It probably is the X factor.
And you know in a session when you've when you've nailed it, and I think you also know when you haven't. So it's palpable.
So, you know, I think allowing people to talk would be the first thing.
So there's some research that shows that physios interrupt within seconds of people starting. So we'll ask a question and then we'll interrupt. And I often have to stop myself.
I might wanna clarify a point, but I'll just make a little asterisk. I need to come back to it.
So I'm just gonna let that person talk.
And I think as a junior physio, you interrupt even more because you've got your list of questions that you don't wanna forget.
But I think as you become more experienced, you're more comfortable with it being a conversation and allowing them to drive the direction that it takes.
And those extra questions come more naturally.
So I think, you know, people having lots of conversations with, you know, family and friends and, you know, just getting more experience with the listening because you also pick up on specific terms.
You'll pick up on their social connections, so much of how they describe their story. You'll get just so much rich information that you can make a note of and and really come back to to help support them.
But I think you've nailed it about the person being at the core.
So Lorimer Moseley talks about the four questions of self efficacy, and this is how I like to frame working with someone.
Someone wants to know:
1) What's wrong with them.
2) What can you do about it?
3) What can I do about it?
4) And how long will it take?
So I think if you think as you're working through with someone, give them a really clear idea of what you think is going on in the picture as best you can, including any gray areas.
That's okay. Humans are messy. That's fine. I'm really honest about that. I'm really honest if I want different opinions.
You know? I think that's that's good. It actually we don't have all the answers. Yeah.
What can you do what can you do about it gives me an opportunity to say, okay, Nathan. We used to think that tendons were inflamed. We used to call it tendonitis.
I’m going to use this as a teaching moment to explain to you what tendinopathy is - explain why exercise is important.
So this is where I'll meet you at your story.
So what we have is: capacity - and load. And your capacity only ever just exceeds the loads you put on your musculoskeletal tissue - so: tendon, muscle, bone.
And what happened, Nathan, is you were training for something and increasing your load, and you did a really big session so you're overloaded, so you had pain.
So what you did is you had a couple of weeks off, and that's what you thought you needed to do.
But what happens to your capacity with a couple of weeks off is it drops.
And then you went back to training, not thinking that you were overloading.
But do you see how you're overloading to your new relative capacity?
But then you think, oh, maybe I didn't rest long enough. So you have another couple of weeks off, and your capacity goes down.
So I'll actually go through your story with you to say, here's how you ended up. You know, you tried this intervention. You had some time off or you know.
And I'll actually meet you at your story with your story.
And then that leads into what can you do about it.
What you can do about it is slow progressive load because that builds your capacity.
So that reinforces that the work to be done is outside of the physiotherapy room.
I'm going to help you, and I'm going to support you.
But, actually, if you aren't on board, this won't go away.
There's actually no magic bullet for tendons. And I'm really honest with people. If there was, I'd tell you. Like, there's no reason I wouldn't tell you.
What can I do about it? I'm here to support you. I'm gonna teach you when to listen to it. I'm gonna teach you what sort of capacity we're looking for. I'm gonna help you get back to what your goals are.
So what are your goals?
And then the 4th one: how long will it take?
Again, I'm really honest with people.
If their calf capacity is, you know, 6 and they want to run an ultramarathon, and I've had that, you know, we're looking at months because we know that improving muscle strength, for example, in that athlete is gonna take 12 weeks. And then we need to reload some spring, and then we need to build our volume.
So you can give people an idea of time based on where they're currently at and where they wanna go and how far away those points are, you know, give or take.
But you can give people a little bit of an idea as to how long it'll take.
The tough sell is that these aren't fast, and people will need to do the work.
Nathan Schechter: Yeah. It's a journey. And I wanted to ask you about that because I think, people can get confused. Like:
- What do I do?
- When do I do it? Like, how do I and wait.
- Do I have to go off by myself?
And so this really is a journey, and you can see where people would be a little hesitant to understand all the ins and outs of that journey.
And then also, like, can I even make it over the mountain?
And then I wanted to ask a lot of people don't. You know?
That's not their, I sometimes think if they could make a perfect pill that would do it instantly, if you could take, a myostatin inhibitor and mix it up with Wegovy and make this perfect pill that would keep you lean and also make you immediately muscular and do it all for you, a lot of people would want that pill.
And so I'm just wondering, when you work with athletes and you talked about it in the beginning, maybe we closed where we started, you said one of the inspiring things about them is that they're so motivated that they really - do you think it's because they're just more gifted, so they are more inclined to do it?
Or is there something about the athletes and the artists that makes them want to stay with that long process that maybe our our day-to-day folks might struggle with more?
Or is it just what is your experience with that?
Because that is ultimately one of the big questions. How do people make that journey? Do people want to make that journey? And what is it that makes it possible for people to make that journey?
Because it is a journey of figuring out, of trial and error, of being patient, and that's so hard for humans, myself included. Patience is a challenging thing. So what do you see with athletes? Does that teach us anything about this longer journey?
That's my my last question for you.
Dr. Ebonie Rio: Yeah. There's no doubt that they have a unique ability to push themselves and motivation to exercise is rarely a barrier the way it can be in general public.
But, also, there are a lot of people in the community that possess those same attributes too. And sometimes their motivation is what tendinopathy has taken away from them.
So they may not have been a lifelong exerciser, but now they can't even, walk their dog around the block.
And so sometimes that can be, you know, the catalyst for them getting into exercise and actually adopting a more healthy lifestyle.
And so I think people's motivations can definitely be different, but dancers and athletes, you rarely, often you're holding them back.
You're not really needing to push them in the same way.
But I think finding out people's why and spending time on that is really important.
And because tendinopathy can be, you know, debilitating in terms of people's ability just to live their life, sometimes by the time they see you, they're they're very amenable to trying. Absolutely. Yeah.
Nathan Schechter: Well, thank you so very much. I really appreciate …