Latest / The STA Clinician Podcast / Ep.198 "Tendon Treatment: What The Research Says” with special guest Professor Peter Malliaras

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Ep.198 "Tendon Treatment: What The Research Says” with special guest Professor Peter Malliaras · The STA Clinician Podcast

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You're listening to the Sports Therapy Association podcast, putting evidence
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back into soft tissue therapy.
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Music.
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Hey people, how you doing? We're
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live, welcome to the Sports Therapy Association podcast, episode 198.
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And 98 my name is matt phillips creator
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of one shot live.com and as always this episode of
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the sports derby association podcast is being recorded live on a tuesday but
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it's not at eight o'clock is it it's at nine o'clock i'm sorry if that's throwing you
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off but really i couldn't come i couldn't have a better reason for
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this because the next three guests basically the next three weeks are in australia
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so i'm getting them up at six o'clock in the morning instead of five so hey
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it's the least we could do isn't it um so yeah it is at nine o'clock i hope
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you still manage to find your way here if you are joining us live but as always
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this will be uploaded as It's a podcast available on all normal apps, including Spotify,
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and the video recording will be on YouTube.
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So yes, this episode is part one of a three-part tendon special,
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giving you, the dear listener, the opportunity to spend an hour in the company
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of three world-leading experts in tendinopathies.
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In part one tonight, coming up very shortly, entitled Tendon Treatment,
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What the Research Says, my guest is going to be Professor Peter Maliaris.
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And then next week on may the 21st also
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at nine o'clock bst british summer time it's going
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to be understanding tendinopathies of the hip and pelvis with the one and
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only dr allison grimaldi and then in part three
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on may the 28th at nine o'clock bst in episode 200 we've reached the big 200
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that's 200 weeks in a row not bad all because of covid so there you go the topic's
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going to be managing tendon pain with special guest dr ebony rio so if you are
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listening to this podcast and And you're interested in, well, you should be.
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You should put everything down to join us for the quality of those guests.
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All our guests are quality.
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But in particular, if tendinopathy is an area of interest to you and you have
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clients who are suffering from tendinopathy in its many forms,
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then you really should kind of, if you've missed tonight, just put the next
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two weeks for free. OK, 9 o'clock BST.
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You can join us on the Sports Therapy Association YouTube channel and also on Facebook if you prefer.
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Right then, as I say, my guest tonight in part one is Professor Peter Maliaris.
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He's one of the most highly respected researchers and educators with regards
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to tendinopathy, co-author of over 100 peer-reviewed publications,
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and is currently Associate Professor at Monash University Physiotherapy Department
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in Melbourne, Australia, hence our slightly later starting time.
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He's also creator of the internationally acclaimed Mastering Lower Limb Tendinopathy course,
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now in its seventh edition, edition which as we'll
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chat later on is available online as a lecture on
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demand 16 hours of cpd and occasionally in the
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uk he's been here last year last time was november and there
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are thoughts in the pipeline that may be coming over next year as well at some
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point so without further ado if you are joining us live in the lounge and feel
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free to ask questions this really is a great opportunity for you just jump in
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there but yeah sit back and enjoy um part one of our attendance special with professor peter malias.
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Music.
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You're listening to the sports therapy association podcast evidence back in the soft tissue therapy,
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good very good uh man how are you i'm good
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can i refer to you as pete from now on because it's just a bit of a mouthful no
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disrespect to the professor title obviously but it's just gonna take
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me a long time um that's before you met yeah you
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don't have to use my title it's really that you can leave that behind mister
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it's so overdone these days mister and so yeah great
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thanks again i can't say so much thank you so much i
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know you're an early starter and you've joined you've probably been for one already but six
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o'clock thank you very much for for making time to join us for this no no problem
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at all happy to be here thanks right so just to say people joining us live it's
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fantastic i've given pete permission just to cut me off completely if there's
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an interesting question in the chat so do people ask questions use this opportunity it's a
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huge opportunity the next hour is going to be for you cecily they're
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saying let's kick oh she's already asked a question i better hide that got
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to be an introduction first cecily i didn't mean questions now that's
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better sarah did not jumping in with a question that's a bit more british evening
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looking forward to this one thank you sarah jesus just calm down a little bit
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okay we'll come to your question later on straight away oh no hold on i think
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it's a joke okay here we go let's kick off with a terrible joke what do you
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call kevin bacon with no achilles tendon.
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What do you call kevin bacon with no achilles tendon i
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feel like the the level of the show is just dropping rapidly
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but any ideas i don't
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know you can write the answer in there kevin bacon with
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no achilles tendon don't know come back to us on that one that's a
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cliffhanger if ever i saw one right looking forward to the
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answer there cecily thank you right so you you
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were our guest in episode 91 of the sports therapy
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session podcast which was just over two years ago
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2022 22 i know i said i'd call i'm
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sorry just i've been really busy but two years later you're back on the shows thanks
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for that how's the last two years been been busy yeah
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it's been good it's been good yeah i've been uh so still working at monash full
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time still doing one day a week in the clinic yes keep busy with that sort of
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stuff still seeing the usual sort of tendon patients in the in the clinic uh
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doing lots of tendon research supervising supervising lots of students so So pretty much just, yeah,
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all systems go the last couple of years. How about yourself?
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It's, yeah, I mean, we're talking about research and evidence and stuff like
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that. And that's such a big theme now.
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And we're finally, I think, moving into quite a nice place, particularly bringing
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just different disciplines together.
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Even last time we spoke, there was probably still battling between physios and
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sports therapists and massage therapists at the bottom of the pile.
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And it was all kind of like people trying to champion their own discipline but now.
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The true spirit of multi-disciplinary care and patient-centered
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focus is kind of working and we're all maybe needed
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in that circle of care so it's for me speaking to people like yourself it just
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seems to be a common thing coming through now that the titles are kind of being
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taken off the wall and people just talking about the patient the patient the
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patient which is which is really cool it's really exciting i agree there's the
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way that i think about is there's a core group of
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enlightened people and they're the ones that are
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sort of following the evidence and trying to
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keep up to date and then there's people in all professions that don't
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bother yeah that's a
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good way of putting it but there's also now this i
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don't know as far as we're seeing without staying on the topic for too long but there's
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kind of what i'm enjoying and it's just my personal bias
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is the evidence is exception the fact that you don't just run your
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clinic according to what the research says that wouldn't be evidence-based you've
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got to take into account the patient's expectations and what the patient wants
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at that particular time we've had a lot of talk about that whole idea of a three-pillet
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stool and that sort of stuff or a funnel approach whatever you like and because
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there is a little bit in england anyway on particularly on social media a bit
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of a kind of a almost fascist like.
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That's not supported by research you mustn't do that and it's like well
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mate if you're just going to do what's supported by research you can have a very quiet clinic
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because not a lot of what we do is supported by research
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or at least it's a bit gray so but hey that's what
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we're going to talk about tonight with regards to tendinopathy massive topic um
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okay cecily kevin bacon without an achilles is called
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footloose yes of course it is footloose it's
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fantastic thank you that's your one joke for tonight done cecily that's
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the card gone no more right so how
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i thought would work today is i had
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a look at research gates it's going to be a little bit like this is your life i'm
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afraid pete we're going to take a trip back time
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and it was because people interested
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i'm hoping there's people who don't know about you because if we're
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just talking to about you to people who already know you it's a little bit of an
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echo chamber so just to stress the contribution
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you've played to research particularly in the
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role not just for tendinopathy i found the
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first paper you did was well the first published one was 2004 which was with
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jill cook whose name will appear quite a few times and i'd quite be interested
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to hear about your relationship with jill cook and how that all started but
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yeah 212 publications for people who can't see the screen if you listen to the
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podcast i've just brought up research gate for peter maliaris.
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212 publications 194 833 reads 6 322 citations this should make you feel very
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old and then And there, the only one I put on the screen, 2004,
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just neovascularization and pain in abnormal patellar tendons of active jumping athletes.
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So I thought as a little intro, how did you get involved in that?
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And how did you get to do it with Jill Cook?
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Right. So basically, that's going back to what, 2004, probably started that
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research in 2001 when I started my PhD.
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And I just sort of was a fresh-faced young physio at that time who was five
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years out of basically training and had done an honours during my undergrad,
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and thought, you know, the next step that I wanted to do was a PhD.
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And it was more just serendipity, to be honest.
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I'd been working with sport, I'd been working with various sort of,
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you know, I guess, overuse, tendons-type problems, but hadn't really developed
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speciality in those areas yet.
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And then the opportunity came up at La Trobe Uni where I did my undergrad and Jill was there.
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And that was, yeah, that was sort of how it all started. And yeah.
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Yeah basically we then planned a phd we planned like three or four studies for a phd did that.
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Finished that in 2006 and this
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was one of them this was one of the studies yeah this was but this
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was this was actually not directly in my phd because
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jill was the lead author it was one that we did with the
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phd data but it was it was related to the
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data collection that i did for my phd so i
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thought my phd data collection basically followed up
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a group of 100 plus volleyballers over
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a season and we looked at them every month and we
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did you know imaging and measures and testing
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and strength and we got a bunch of different questions answered from that data
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collection and this one was really related to what's the relationship between
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pain and and sort of other imaging measures like Doppler in the tendon.
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So back in those days, in the late 90s, early 2000s, there was very much a mechanical
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view of what tendon pain was and what tendinopathy was, and it was all about
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what's going on in the tendon.
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I don't think we ever talked about things like the biopsychosocial model or
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anything else in those days, and we would,
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you know, look at what could be the cause of problems from a very mechanical lens.
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And one of the ways that we looked at it was are these vessels,
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these blood vessels inside the tendon, could they be contributing to the pain that we're seeing?
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And what we found in this study is that maybe they are related.
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And that's probably still true. True, there's some relationship between things
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like Doppler, but it's not the full story as we know it.
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Now, it's certainly not a clear relationship between any pathological feature
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within a tendon and pain,
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even though some of them might be related in some studies and in some subgroups.
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In other subgroups, there's no relationship.
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So it's quite variable. And that's one of the challenges of looking at the literature.
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It's not always consistent. and often that's explained by study design or by
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you know the populations people are looking at but that's sort of yeah you're
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right that's sort of where it all that's sort of where it all started.
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That's really interesting you know to hear how things have changed and it doesn't
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sound like 20 years ago it's doing my brain a bit thinking 2020 2004 was 20 years ago but it is,
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is so back then you said like
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terms like biopsychosocial weren't even around even though
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the theory was put out there relative to i think psychology as
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opposed to health care or something but when you look
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back at how your brain was working then do you
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kind of think oh what was i thinking or is this all ridiculous
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or do you kind of accept the fact that's what we had at that time and
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and we were going with it because there's a lot out there there's a
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lot of people sadly we see it's a social media people standing on soapboxes saying
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oh you're just looking at mechanics you're not even considering the psychosocial
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factors and it's all a little bit yeah but we were all doing something different
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5 10 15 20 years ago and if you weren't doing something different then you're
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lying because you know so how do you look back at yourself 20 years ago do you
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do it with what was i thinking or do you yeah i was doing it as good i look i personally.
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Don't worry too much about the past it's all about i think it's all about i
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think we're all on a journey of learning and improving and you know regardless
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of what you thought even yesterday,
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as long as you're improving you're thinking you know you're you're
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you're willing to change and willing to improve that's the that's the main thing
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for me so i i don't i'm not oh so i've got is that here that's right people
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listen to the podcast there's a there's a dog on the screen in case you hear
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it's not actually heat i'm slobbering it's a beautiful I'm trying to lick my face off.
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So, yeah, look, I just think there's no shame in having, you know,
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I guess it comes back to our education.
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We're all educated and a lot of us still are educated in the biomedical model
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and that's, you know, to be able to shake that off and move beyond that and
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practice in different ways is a positive regardless of when you come to it.
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So I think, yeah, I don't really think there's, and back in those days,
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you're right, it was sort of what everyone was doing and what everyone was talking about.
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It's it's it's sort
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of taken a while probably longer uh
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in tendinopathy but i think it sort of
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goes back to the conversation we had earlier we're all we're all
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getting to an evidence-informed view
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and perspective now of different conditions not
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only just you know things like back pain and that's
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uh that's a really reassuring thing i think that's really good that's
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good i mean that's good to hear for you and it was a bit of a leading question but i just know
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that for a lot of our listeners do worry about the fact that they've especially
15:05
with with with sports therapy
15:08
and sports massage therapy because a lot of
15:11
the courses out there still have got dodgy information they're still
15:14
being told some courses that you know things like you're
15:17
breaking down scar tissue that you're increasing the risk
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of cancer or miscarriage and
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all these sort of things and some people are horrified and they
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get so worried about the fact they've been told something it's not quite true
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they find it difficult to move on when really your learning
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process is just like you said tweaking it a little bit evolving and
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not looking back and going oh what was i thinking how embarrassing yeah yeah
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you know especially with patients i think a lot of therapists are scared to
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go to their patients and say you know what we were doing for the last month
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or two i've just read something interesting we're going to tweak it a little
15:48
bit we're going to try and do something a bit different i think would you say
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the patients are going to be less scared about that than therapists are.
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Yeah, absolutely. Patients love that. Patients appreciate that.
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They appreciate when you're honest, I think. And you say, look,
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these are the limitations of what I know, or this is what I think.
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Maybe you need to try something else.
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I think, yeah, honesty is always, I think, appreciated by patients.
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They take that on. They really appreciate that.
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And I think it's the same with us and what we know. And not everyone knows everything.
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And we're all learning, I think. And And that's the way that I always view it.
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And that's why I do research, because we are always learning.
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And I certainly don't know everything nowhere near it when it comes to – well,
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when it comes to – my wife would say I don't know much about anything.
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And she's probably right. But also in tendons, I don't know everything.
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And that's good, because otherwise I wouldn't – I'd be out of a job.
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There you go. I mean, if Professor Peter Maliaris doesn't know anything about
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tendons, then you guys have got nothing to worry about.
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Out so that's great now it's really it's just really healthy to hear so i appreciate that.
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Let's um bring up let's change what's on the
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screen here and just kind of move through time a little bit and just
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hear your thoughts if the particular paper might just stimulate some
17:06
thought with regards to that paper or might be another one which comes
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to mind but i just brought a few up in chronological order i'll read
17:12
it out on the screen for people who are listening to the podcast
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this was with zoomed forwards at just a year now 2005 factors
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associated with patella tendinopathy among a cohort of volleyball players
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so patella tendinopathy obviously a lot of our listeners who
17:26
allow to work with injury will come across
17:29
patella tendinopathy so i'm just interested to hear about what you
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were looking at at the time and how things have changed with regards to yeah
17:35
managing patella tendinopathy yeah yeah we
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so yeah that you're really testing my memory
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now matt that's right i told you i'm sorry we we
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basically with that one we were interested in
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so it was a it was a sort of long-term prospective study and we're interested
17:58
in looking following up and we did a bunch of work on we did this sort of cohort
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where we followed people up for you know six months and it was all volleyball
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players and we're interested in you know does their pain change,
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does their imaging change, if those two things were changing together,
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if they were related at all.
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We're interested in other factors. We measured a bunch of strength and hopping,
18:24
jumping type variables, and we were interested in some of those variables as well.
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So sort of trying to understand what factors, impairments are present and also
18:35
trying to get at some of the risk factors as well. So that's sort of where that came from.
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I guess the biggest learnings from that that we had sort of led to...
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It was sort of interesting in a way because we sort of found that.
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And I guess we sort of appreciate this more now, but we didn't see a progression of pathology.
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People can play volleyball at a very high level and
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still not experience falling in
19:19
a heap and getting much worse and their tendon getting worse and
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those types of things even though they've got a
19:25
quite severe problem so um the
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things like that i guess were the were some of
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the learnings that came out of it people are quite resilient
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and even people playing volleyball jumping multiple times
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a week with a painful patella tendon some
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of them got better during the season some of
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them got worse some of them stayed the same and we we weren't
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really able to relate that to loading very clearly
19:51
and it was probably other factors as well
19:55
so that was interesting and
19:58
it and again it sort of challenges your mechanical view of
20:02
load is everything when it comes to attendant you
20:05
know we're sort of overloading people we should
20:08
be advising them not to do these activities because
20:12
they're potentially you know damaging so so
20:15
that was that was sort of that was part of it the other part that came out of
20:20
that was that sort of led to some of the studies that jill went on to do for
20:26
the continuum model so that cohort so it was it was quite an it was quite a.
20:34
Quite a good bit of data that we're able to collect with
20:37
that and move on to move on to sort of understanding
20:41
some things jill went on to look at
20:44
it in in a lens and obviously not
20:47
just with that cohort but with some other stuff with a
20:50
lens of how do tendons change over time because
20:53
what we found with some of those prospective studies
20:56
is that you do get you do in
20:59
the patella tendon at least you get changes that
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you know sort of i guess you know very
21:06
mild first and then it goes
21:08
to a more severe what was termed degenerate type
21:12
change degenerative change so and
21:15
that came from that came from that cohort of
21:19
that phd cohort so we saw that in
21:22
those volleyballers some of them were normal healthy tendons
21:26
and then they went to this reactive what was
21:29
termed reactive which was mild pathology then they went to more severe so so
21:34
there were some yeah so some interesting things that did emerge from from that
21:39
data collection so that's interesting i'm glad you mentioned that because that
21:43
was kind of seen that the whole even now the the continuum.
21:48
Of jill cook and craig perdon this is kind of mentioned the continuum of tendon
21:51
pathology Can you explain to listeners who aren't aware of it how that affected
21:56
clinical practice in terms of if you do appreciate the three different stages
22:00
and how does that change how you're managing tendinopathy in patients or clients?
22:05
Yes, look, it did have quite a profound impact on clinical practice.
22:10
So it was at the time quite, you know, there's been lots of different advances
22:15
throughout the last three, four
22:17
decades, you know, with Hock and Alfredson initially and then Jill Cook.
22:23
And I think that sort of made people think more about, I think it did make people think more about.
22:32
I guess the principles that I took out of it were things like changing in load,
22:36
you know, getting people to appreciate the effect of load, both positive and negative on a tendon.
22:45
Thinking about different ways to manage people who loaded,
22:51
who have sort of come to get a real sort of severe response to load,
22:57
which we see clinically, versus people who are just not really changing that
23:06
much and load is not the factor.
23:09
Maybe they've had it for a little bit more, a little bit more persistent.
23:12
So they were the positives that came out of it.
23:15
Probably the negatives that came out of it were a very biomedical lens,
23:20
again, focused on tissue and focused on load.
23:25
So again, we've moved beyond that a bit and we know that even though the continuum
23:30
taught us that people do present differently in terms of their symptoms,
23:35
it also focused us on pathology and how that relates to pathology,
23:40
which we know is a bit of a slippery slope because we don't have any real strength
23:48
of relationship between those two variables and that is pathology and pain.
23:52
But I think, you know, overall, there were some principles that clinicians can
23:56
take out of the continuum that were,
23:58
you know, hugely positive and helpful, as well as now some of the things that
24:04
we look back on and think, you know, I don't think it's positive to be thinking about.
24:12
Pathology and how pathology can influence our management and that's sort of
24:18
in a way one of the things that the initial continual model was putting forward
24:25
so that's that's that's sort of,
24:27
i guess current day interpretation of where we can go with the continuum at
24:33
the moment but you know absolutely it was ahead of its time and and also helpful
24:38
at the time and very popular as well.
24:41
Interesting i guess what we're talking about i mean for
24:44
me everyone's gonna have their different moments but another thing which struck me
24:46
and i can't remember when people first started talking about
24:50
it but it appears in quite a few papers and that's the change in
24:53
nomenclature in the fact that when suddenly people were talking about tendinitis
24:57
and then suddenly i meant by things around for me it was maybe 2010 or 12 or
25:02
something like that it was like oh no must be talking about tendinitis anymore
25:05
and that was kind of in reference to hold on it's not all inflammation which
25:09
is a big thing because there's probably still listeners out there,
25:12
today who not by but no fault of their own it's just what
25:15
they've been taught it's where their education has taken so far who are
25:17
still treating all tendinopathies with as an inflammation and
25:20
they're giving their clients NSAIDs and stuff and and they're getting
25:24
frustrated and getting a bad reputation because their clients aren't getting
25:26
better so do you remember do you recall when the kind of changes in names came
25:30
about and were you involved in that and yeah it it was it sort of if you look
25:37
at what is it is it google engrams where you can look at the names over time.
25:42
I think it is i mean i've got the only
25:46
thing i found online was i think it was karen khan and
25:49
jill cook in 2002 they had a time to abandon the
25:52
tendonitis myth i don't know that that was after a
25:54
period of thought or other papers but that wouldn't be
25:57
the one i heard because i i was not as as clued
26:00
up back then in 2000 but yeah they said time to abandon the tendonitis myth
26:04
which but i think they'll refer to my fully it's what i figured for google engrams
26:09
now and that shows you in the in
26:13
the online world what what's the usage of those words are if you look at.
26:18
Tendinitis it sort of peaked around nine probably just before 2000 and now tendinopathy's
26:26
just overtaken it in the last few years in terms of representation online but
26:31
it's still yeah it's They're still used interchangeably.
26:35
Basically, they...
26:38
Yeah, I think officially, to answer your question, officially Nicola Maffoli put out a paper.
26:45
That was the first one that talked about tendinopathy. That was probably early 2000s, I reckon.
26:51
And then slowly, slowly, slowly, it started to then become more used.
26:56
But we recently had a consensus among international experts where we officially
27:01
put forward that we should be using this tendinopathy term, not tendinitis.
27:05
And it's not wrong. wrong and as you say it's
27:09
it's sort of with we thought initially in the
27:11
80s that it was all about inflammation and that then
27:14
leads people to go down the path of resting and taking
27:17
anti-inflammatories which doesn't really help in the long term for
27:21
most people so so that partly that
27:24
reason but also the fact that
27:27
the pathology is much more complex than just inflammation
27:30
and it's it's it's probably a
27:33
it's probably a little bit of a simplification to
27:36
say it's just tendinitis and so tendinopathy
27:40
is a broader term and it can encompass inflammatory
27:43
changes and other things as well so that's sort
27:46
of yeah where it's gone but it's good to see google
27:49
mgrams it's starting to become more popular but
27:52
if a patient calls it tendinitis i'll just go with it
27:55
i'm just you know i'd say look we actually it's called
27:58
tendinopathy and this is this is why but you.
28:01
Know tendinitis is is fine if they
28:05
want to call it yeah that's absolutely fine
28:08
it's probably a bit patient centered as well unless they're
28:12
going home and necking ibuprofen or something you know yeah exactly
28:16
exactly yeah so it's all about their beliefs and
28:19
what it what that term causes them to do
28:22
rather than the term they use hey there
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29:31
So back to back, you're just perpetuating the kind of generalisation about Aussies at the moment.
29:37
It just couldn't be more laid back. If the patient wants to call it tendonitis,
29:43
they can call it tendonitis, it's fine.
29:44
So chill that. Right, let's bring up, stereotyping I'm here.
29:49
Right, let's go to the next few years down the line and have some of this in here.
29:54
Right so this was imaging which you've done a lot of papers
29:57
on as well over the years this was 2005 okay
30:00
so still in the same kind of time it hasn't you ever got to remember this exact
30:03
paper but i'm interested in general about where we are or where
30:06
we were and where we are now with regards to imaging because we
30:09
hear a lot about you should only use imaging to
30:12
confirm your hypothesis you should never use it to
30:15
try and get a hypothesis and that's maybe
30:18
a generalization what's the what's your history with
30:21
imaging and tendinopathies yeah it's
30:24
interesting so basically i i do use imaging in the clinic in my clinic i mainly
30:32
see achilles tendon also some patella and some sort of a spattering of other
30:38
tendons but i do use imaging and i find it useful it's it's not it's It's absolutely,
30:44
I guess the first thing to say, it's absolutely not necessary for diagnosis.
30:49
So if you're trying to diagnose a tendon problem, imaging is not necessary.
30:55
You can, well, the diagnosis is clinical because it's a clinical pain condition that we're treating.
31:01
So you don't need imaging for the diagnosis.
31:05
It can be helpful for, I think personally, And personally, the biggest reason
31:12
I use it is for patient engagement.
31:15
So what I mean by that is if the patient sees that you're taking the time to
31:20
do the imaging yourself,
31:22
they feel rightly or wrongly that you've understood their problem at its core,
31:30
which is the tissue level.
31:32
So that sort of, I think, is quite powerful that I've found in my practice.
31:36
And it's just, it's really just really from, I guess, an interest in using it
31:42
in research that it's sort of crept into the clinical work.
31:45
And I've been imaging people there probably for the last, say,
31:49
15 years. But as I say, mainly the Achilles and patella.
31:52
But there are also other reasons to look at imaging.
31:55
And that could be if the diagnosis is unclear.
31:59
Or if people are not responding in the time course that you're thinking,
32:02
they should be responding.
32:04
You know, if you suspect a red flag, if you're considering an injection or invasive
32:09
procedure. So there are other reasons to image.
32:12
But for me personally, they probably don't, they're probably quite rare.
32:19
So looking at Achilles, I might image 20 or 30 people with an Achilles problem.
32:25
Problem and you within that
32:28
20 or 30 people you may not find many with a with a
32:31
differential condition or other things going on
32:34
that sort of warrants the imaging but you
32:37
do commonly see benefit in people who you know are reassured by your explanation
32:46
of the imaging and how you contextualize the imaging so i think that is for
32:50
me you know a very powerful thing and a powerful tool that we can use.
32:55
Having said that, I know there'll be a lot of clinicians listening thinking,
32:59
I don't use ultrasound in my clinic and I haven't got access to ultrasound.
33:02
You absolutely don't need it. You just need to be able to explain and understand
33:07
the image and explain it to the patient.
33:10
That's really, really important, I think, because patients do worry about what
33:16
is on their scan. They worry about the imaging.
33:20
They worry about what's going on inside their body and we know that from a lot
33:23
of the qualitative work that we've done asking patients what they what their
33:28
experience is with their tendon problem so that I think having that ability
33:33
to contextualize the images is very very very important.
33:39
Yeah, that's interesting. That's a love. Again, it just shows an evolution of
33:44
thought of the patient would really benefit from this, the visual,
33:47
to help that therapeutic alliance, and they want an explanation.
33:52
Yeah, just playing devil's advocate, but is it still the case that,
33:55
like, for example, symptomatic, 10 people suffering from tendon pain may have
33:59
an imaging that doesn't show anything and vice versa? Is that not a problem?
34:03
So, yes, yes, yes, yeah. Yeah, and that's the reason why we shouldn't use it
34:10
or hang our hat on it for diagnosis.
34:13
So we know that there's a whole stack of people out there who will be having
34:18
imaging changes but not have any pain.
34:21
That's really common. Now, in that paper that you flashed up,
34:24
we also showed the opposite, which is people who have tendon pain but don't have imaging changes.
34:30
So the two ends of the spectrum are possible. now
34:33
the one that we've shown in that paper what
34:37
is not as common it's it's it's far
34:39
more common to have some pathology changes
34:42
when you've got imaging sorry some some pathology changes
34:46
when you've got pain it's far less common sorry it's completely confused now
34:52
must be six o'clock in the morning it's it's far more common to have pathology
34:59
and no pain that's really common The other one is less common.
35:04
That's why we published that paper, because we were surprised in our cohort.
35:08
And again, that goes back to the large cohort I was talking about earlier.
35:12
We found these people who had clear patellar tendinopathy, but their imaging was completely normal.
35:20
So, you know, if you are seeing that, it's possible that you've still,
35:25
trust your clinical diagnosis.
35:27
That's the take-home message, because that's the most important thing.
35:31
Then that's good to hear it's good to hear with regards
35:35
to that what are some of the i mean
35:39
i suppose to a certain extent we can generalize if we're
35:41
working with tendons what are some of the kind of things which
35:44
flash up and maybe the subjective which take us
35:48
down the road thinking this is probably a tendon problem compared to
35:52
a muscular issue or bone issue what are some of their kind of giveaways yeah
35:55
yeah yeah it it does come
35:58
down to it does come down to things like the pain being localized to the tendon
36:04
it comes down to load related pain so some pain with activity generally sometimes
36:10
after it comes down to there will be things like tenderness on the tendon.
36:18
It comes down to what else? They're probably the main ones.
36:24
We recently did a consensus that we're writing up now for publication.
36:28
We sort of had a consensus of 51 international experts trying to understand
36:34
what the best ways to diagnose Achilles' anopathy are.
36:38
And I say that to people and they sort of think it's obvious.
36:43
It's actually easy to diagnose Achilles' anopathy. but it
36:46
was interesting how many really interesting thoughts and
36:49
diverse thoughts came up in this 51 international
36:52
experts around the world who see lots of achilles even there there was quite
36:58
diverse views about what we should be doing but that's they're the sort of things
37:02
that came out top of the list basically it's it's simple stuff like this where
37:07
the pain is is it load related and And, you know,
37:11
does it flare up with things you think it will flare up with,
37:14
like walking and running?
37:16
That's for Achilles, obviously. So, yeah, it comes down to quite simple sort
37:22
of clinical questions more than the actual tests and the imaging that we do.
37:29
That's another great message to hear as well. So, yeah, form your hypothesis
37:32
with the subjective and then test it using the objective rather than going straight
37:37
to the objective. That's a nice message to hear. Exactly. So by the time you
37:40
finish the questions, you're pretty much already there.
37:43
I mean, as you say, you're sort of just confirming it at that point.
37:47
Yeah. And we've heard from a few guests now that if you – I'm terrible at this,
37:53
but it's been mentioned a couple of times, but if you ever find yourself banging
37:56
your head against the wall thinking, what is going on here?
37:59
I've missed something here and it's driving you mad, then the advice is just
38:02
start a conversation again with your clients. Yes.
38:05
And let them go over it again because you've probably missed something or maybe
38:08
you haven't put them in a state of mind where they've revealed it.
38:11
They might not have told you something which is important.
38:13
The answer is still going to be with them rather than doing more tests and doubting
38:16
yourself. I can't remember who said that, which I give them credit.
38:19
That's great advice. Yeah, listen to your patient, basically.
38:23
I'll remember shortly. Anyway, what about – I'm just interested how supported it is by the research,
38:28
but I know in my own practice when it comes to tendinopathies,
38:32
we're looking out because this applies to to assessing and
38:36
also when it comes to loading the whole kind of 24 hours like
38:39
for example if they say well they
38:42
might even realize but the pain is coming 24 hours
38:45
after the activity but is that
38:48
something if you get to look out for is that something which might be a giveaway
38:52
as well this kind of delay this kind of window where the tendons don't seem
38:55
to react yeah look it's it is quite variable and that's where a lot of the discussion
39:01
was in this Achilles consensus group around diagnosis because it's,
39:06
you know, some people have,
39:07
most people have morning stiffness, but some people don't.
39:11
Most people have that delayed pain that you're talking about,
39:14
but some people don't. So it is quite variable.
39:18
It's not, none of these things are completely universal.
39:22
And that's where the nuances of diagnosis come in, because you sort of look
39:27
at the whole package together.
39:29
You don't look for the one single feature. So I think that's right for most
39:34
people, but it can be missing for some people as well.
39:38
And we sort of need to consider that. So you've got to, yeah,
39:43
not go by one characteristic, but kind of combine them all and see if there's
39:46
a... How about the whole... What was the other thing I wanted to mention to
39:49
you? Yeah, the kind of warm-up...
39:52
Effect where i mean again it might be confirmation
39:55
bias but we do find that with runners with achilles tendinopathy
39:58
or maybe a hamstring that yeah one of
40:01
the problems is when they start warming up they think oh it's gone i'm feeling
40:03
good now and then they overstep the mark and they go that too much of a distance
40:07
and especially and it might start hurting later on because they had that positive
40:10
experience in the beginning they're kind of like not sticking to the protocol
40:14
so is that something which will vary or is that maybe another characteristic
40:17
of tendons that that that will also So very,
40:21
yeah, along with everything else, yeah.
40:23
So some people do get that very, very clearly. Other people don't.
40:29
And also it may be that they get that, but maybe it's not their Achilles.
40:35
It's something else. So this is where the nuances of diagnosis are.
40:40
Most people think diagnosis is quite simple, but there is a bit to it.
40:44
And I'm looking forward to writing this up because it was, going back to learning,
40:49
which we were talking about earlier.
40:50
For me, as an experienced Achilles clinician,
40:54
thinking, oh yeah, diagnosis is quite straightforward, but doing this study,
40:59
it was a really good learning experience as well because you got a lot of different
41:04
perspectives from very experienced people,
41:07
which also changed the way that I think partly as well.
41:10
So yeah, looking forward to presenting that. And I think it will
41:13
be some clinically useful bits in
41:16
there for clinicians as well so we're just preparing it now amazing
41:20
and did you say that was like 51 of you getting together and
41:23
just talking that's gonna be incredible 51 from all
41:26
over the world yeah so yeah it was
41:29
it was good it was a full it was a four-part delphi study so just into like
41:34
uh questionnaires online over four parts where you reach consensus yeah not
41:39
easy to get a consensus a bunch among a bunch of of experts because you get
41:44
very strong opinions of course,
41:47
You get essays of comments, basically, that we have to sort through.
41:51
You know but it's it was good it was a good process that's cool
41:54
okay how about i'm just conscious of
41:57
the time what about when it comes to like another
42:00
word treatment i think i can't remember again who it
42:02
was but we need to move away particularly people from sports therapy
42:06
and from a manual therapy background i think they need to move away from
42:08
the word treatment because it sounds like we're just going to do stuff to it but so with
42:11
the management with the loading protocol you talk about i'm interested
42:15
in moving on in fact i think the next slide kind of mentions is
42:18
the buzzword i wanted to bring up let's put
42:21
it on a hole there eccentric so i'm
42:24
interested about how far the
42:27
evidence supports current themes in loading like the difference of starting
42:32
off with isometric and then going to eccentric and then slowly bringing in some
42:36
concentric is that something which is still quite supportive or i i think the it's there's not really,
42:46
what there's not really any evidence from what what
42:49
what people put forward and i and myself included
42:52
in some of the topical reviews and some of
42:55
the narrative reviews that are sort of clinically focused for people
42:58
with a lot of people have put forward the view that you know you start with
43:01
the centrics you go to isotonic you go you go to stretch short and cycle or
43:06
hop in and jump and other things that involve speed and power there is not there's
43:12
only one study that i'm aware of in the whole literature that supports that.
43:17
And that is the study by Breda published a couple of years ago in Patel Tendon,
43:22
where they compared that approach to the approach of just doing eccentric training.
43:28
And they did find that it was superior.
43:30
They did find it was better. So, I mean, that's at least some evidence for a progressive approach.
43:35
Personally, the way that I think about it is you're trying to recover someone's
43:40
ability to do something that they enjoy doing.
43:42
So it's more about what's that
43:45
thing that i enjoy doing how can i break that up into
43:48
small parts and get to it eventually and that's
43:51
sort of and if that does involve going from isometrics to isotonic and then
43:56
going to whatever activities they enjoy fine but some people can get there in
44:02
a more sort of direct way and just start the activities they enjoy so i think
44:07
i guess what i'm saying is you don't need to do isometrics.
44:11
You don't need to do isotonic for some people.
44:14
You just need to recover their function.
44:16
So I think moving towards more how can we get someone to be able to achieve this goal is, I think.
44:27
Probably where it is starting to move to rather than, you know,
44:33
I have to go through this rehab pathway that involves all these different elements.
44:39
And I'm not saying not to engage at all in rehab.
44:44
Rehab is, I think, important for a lot of people as an avenue for getting them
44:48
towards being able to do the things that they want to do. But we don't have to be so...
44:55
Wedded to an approach where we go through all these phases and it has to be
44:59
isometric first, has to be this second.
45:01
I think just looking at what they would benefit from and that's where the skill comes in.
45:07
So would they benefit from maybe having a stronger muscle?
45:11
Would they benefit from doing things, you know, in this functional pattern versus
45:16
that functional pattern?
45:18
Would they benefit from doing things
45:21
that involve a little bit of power and speed for their
45:24
tendon or a bit of hopping and just trying to
45:27
understand you know where that person
45:30
is at what type of benefit they'll get so that
45:33
that's yeah probably is a long-winded answer
45:37
to your question no it's great no i
45:40
think it it reminds me of actually i
45:43
was looking i don't know whether this was in one
45:45
of the abstracts one of your papers or whether it was something that
45:48
i just came across when i was looking but it was
45:51
um the idea of principles instead of recipes was
45:54
that something you made to but i mean that's what you're making with
45:57
me but yeah it sounds sounds sounds like
46:00
something i've come across i can't remember yeah i think that's
46:03
quite a nice advice isn't it we are teaching in principles so yeah in theory
46:08
make sure they can do some isometric and see if they're happy with it because
46:12
they might be surprised that they can't do it and then move on but it's not
46:15
like a recipe you have to do two weeks of this and then so i think that's and
46:18
that should be also kind of common sense, really.
46:21
Just how is the patient getting on with it rather than, oh, according to this,
46:24
I need to do this now. But I'm fine.
46:27
Don't interrupt me. It kind of is common sense, you know. What about… Exactly right.
46:32
Because it's sort of getting back to the orthopedic days, isn't it,
46:35
where they had like a protocol and would say, you know, two weeks you do this, three weeks you do this.
46:40
It just doesn't work like that in the real world. But I guess that's another….
46:46
Yeah, I can go straight to that now. I just put in a pin in one idea and just come out with that one.
46:50
I think that's another thing which is important with tendinopathy as well is
46:53
it's difficult for that reason to give like a time frame.
46:57
It's important to let the patient know because it could go on for a long time.
47:01
But then you should be prepared that some patients might kind of accelerate
47:05
quickly through the rehab and just do something incredible.
47:08
But that makes it tricky with patients, isn't it? When they say,
47:10
how am I? I suppose, again, it takes us back to you've got to be honest and
47:13
just say, well, it depends how you react.
47:14
I can't give you an answer, I guess. You do, you do, yeah.
47:17
It just depends on the individual.
47:19
I was in clinic on Monday, so
47:22
two days ago, and a guy walked in who was literally walking on their toes.
47:27
He was walking on his toes. So he limped in to the consult room, walking on his toes.
47:34
And I thought, here we go, this is going to be a real severe tendon,
47:37
Achilles tendon, because he can't even walk on it.
47:40
Turned out his brother had had two ruptures of his Achilles tendon,
47:45
and he was petrified of rupturing his Achilles tendon so he was just protecting
47:50
it he was walking that way and he'd been doing it for three months and this
47:56
guy had this guy had almost no pain whatsoever.
48:01
But he was walking on his toes for three months trying to protect it from rupturing
48:06
so it's it really does you know he was pretty much fixed him in one session
48:10
when I when I reshored him He was hugging me when I said to him,
48:17
it's not going to rupture, don't worry.
48:21
It's incredible how diverse people present and how their beliefs and other things and how,
48:28
as you say, the time course can be quick for some if you're sort of able to take them down a path.
48:38
So it's yeah it just it really is yeah some
48:41
some people need need lots of input and rehab and
48:44
and you're right some people will need that reassurance of yes it's going to
48:48
take a long time and this person you're talking about without giving too much
48:51
away would were they an athletic person or were they non-athletic or he he's
48:56
a he's not an athletic person he's he works he's he's like he He works in a
49:01
salon. He's on his feet all day.
49:04
On his feet all day.
49:08
And he was telling me his patients are sort of giving him weird looks.
49:11
Not his patients, his clients are giving him weird looks because he's limping around.
49:15
But he does do a lot of – he does a bit of gym stuff.
49:19
He's got a trainer and he does some gym stuff.
49:22
He's also probably giving a bit too much away now, a musician where he does use his foot as well.
49:30
Okay, so that falls out of the bag, Joe. Yeah, yeah, there's a few things there,
49:35
but yeah, just a very interesting presentation.
49:38
Yeah, amazing. Yeah. Amazing.
49:42
I wanted to, what was the thing I put a pin in? Oh, yeah. So heavy,
49:45
slow resistance is something which we see a lot, a lot of people proposing it,
49:49
And it seems to be that that's what tendons respond best to and,
49:53
you know, reduce the volume.
49:55
And is that, again, something which is supported by the evidence or it's just
50:00
a logical way to do it or what?
50:02
Well, I think it's, when you're talking about this type of exercise rehab,
50:08
you've got to also be clear about what the outcomes are.
50:12
So if you're if you're looking at
50:15
the outcome of what the tendon responds
50:17
to if we interpret that as tendon
50:21
getting stronger then heavy slow resistance is probably a good way to go because
50:25
the tendon will adapt with that type of loading but if you're talking about
50:28
the outcome of pain just getting people less painful more functional able to
50:34
do more things it probably doesn't matter what type of loading approach you take.
50:39
And that's really clear in the evidence. You can get people's pain better by
50:44
doing the old-fashioned eccentric, by doing every slide, by doing other things.
50:50
So pain outcome is different to, say, tendon mutation outcome.
50:56
And there's no clear evidence that we need to adapt the tendon or get the muscle stronger.
51:02
Maybe you can make the the argument that if someone's got a really weak muscle,
51:06
really weak tendon, then it's a beneficial thing to do heavy, slow resistance.
51:12
So I can see that argument that people make, but it's also important to know
51:19
that you can maybe go back to that approach we were talking about earlier and
51:22
just gradually reload someone in a functional way.
51:27
And that might be enough for some people without
51:31
a heavy slow so so that's almost like a cft
51:34
approach like they're doing back pain they're just you know you're just gradually
51:38
starting to load someone and this guy that i saw that i was talking about that
51:42
i saw monday that's pretty much what i did with him yeah yeah so i didn't bother
51:47
doing because this guy's been walking on his toe for three months he's probably
51:51
got quite a strong cough.
52:00
Someone like that i i just start with um
52:03
just just start to load it again just start to load
52:06
through dorsiflexion get used to doing that again just see
52:09
what happens gradually give him some goals about
52:12
loading over a step and that might be enough as opposed
52:16
to say going through right we need to strengthen your tendon
52:19
we need to strengthen your muscle we're going to do a
52:22
heavy slow resistance type program with you so
52:25
it's it's it's useful but
52:28
i think it comes back to what's the
52:31
goals and as is that goal important for that person yeah
52:35
brilliant answer great yeah again i was thinking with the runner's
52:38
head on where we're looking at each step is going to have to
52:41
deal with quite considerable loads and multiples of body weight so
52:43
but yeah if they're not going back to run then they're
52:46
not going to need either that heavy load per step or that cumulative load if
52:50
they're running miles and miles what about if we are with regards
52:52
to kind of like synthesis of collagen and kind of again
52:55
looking a bit through the biomechanical lens but if we know there's
52:58
been degeneration if it's a chronic thing we need to stimulate that repair is
53:02
that where the idea that the tendons do respond to heavier slow as opposed to
53:08
yeah that's where it does come in exactly yeah so the the weight of evidence
53:12
at the moment does suggest that tendons respond to are heavier.
53:17
So if you do want to get the tendon stronger, it does have to most likely be
53:22
the heavier type stimulus that you're doing.
53:25
There was actually a really interesting paper that I did a Twitter post on it
53:35
last week or the week before, where.
53:39
They found that even moderate intensity loading did lead to adaptation in the tendon.
53:44
It was by the group in Copenhagen. They found that 55% of 1RM,
53:50
because the heaviest low resistance is all 70% 1RM or above.
53:54
This time they did 55% and they still found adaptation in the tendon, which is interesting.
54:01
Yeah, and I think that's one of the first studies to show that.
54:04
So it seemed like maybe that
54:07
is also being challenged a bit that thinking that
54:11
just go super heavy with the tendon now that's
54:14
that's only one study so we do need more population were they so who were they
54:18
who were they they did they did young they had a young group and they had an
54:23
older group of fit and healthy people not for a particular sport it's just not
54:28
not for a particular sport from memory just fit and healthy people and there was a group
54:34
that was older, say over 55 or something, and the group that was younger.
54:38
Yeah, it was interesting just to read that.
54:42
So there might be options with how we look at it as well. Yeah.
54:47
So it's still kind of, in summary then, in a way, it's still not black and white at all.
54:55
In conclusion, you've still got to base, I suppose really it's the principles
55:00
and not the recipes, which seems to be the message that sums it all up.
55:04
We have got some ideas, but always apply it to the patient in front of you.
55:09
And also kind of like some of them are simple, like it's not always going to
55:12
be an inflammation problem.
55:14
I think that's probably even today, I don't mean that disrespectfully to people
55:18
thinking, well, I thought telenochloroethy, we always give them inflammation
55:20
and give them to rest, but that's something where some therapists still need
55:23
to update a little bit and move on.
55:28
Fantastic. Oh, there's so many other papers and stuff I wanted to go through
55:31
with you, but it's just too interesting.
55:33
We've got to do two hours next time. Oh, okay. Well, you said that now,
55:37
I've got it recorded as well.
55:40
The best thing I can do, the best use I can make of this time now is probably
55:43
to let people know about if they are interested in the education and they enjoy
55:48
the way you've put it across.
55:50
Then you've got online versions of your famous course, haven't you,
55:55
which people can tap into as and when they want.
55:58
I'm just going to put this on the screen for people who are watching the YouTube
56:00
recording or join us in the live lounge.
56:03
So tendinopathy rehab
56:06
the website you need to go to let me
56:10
just check it's it's it's dot site isn't it
56:13
it's not a con or something yeah exactly yeah yeah
56:16
let's check that and if they go there then they can find details for the online
56:21
course is it for anybody the online course i've got another shot here we pretty
56:25
much have all types of all types of people doing it so we you know So from doctors to physios,
56:34
myotherapists,
56:35
sports therapists, pretty much everyone, yeah.
56:37
Fantastic. We get, yeah, we get a range of people who do it, yeah.
56:43
So it's basically like it's online modules covering hamstring,
56:49
gluteal, patella, and all the foot and ankle tendons.
56:54
Marvelous and i guess because
56:57
people are working at their own speed and
57:00
kind of level and they can look things up and take as
57:03
long as they want to get through as opposed to trying to keep up with the course
57:05
or something so they've got that advantage yeah yeah and there's there's modules
57:09
you pass the module you you have a quiz and then you go to the next one so it's
57:14
like a gradual thing you can take your time and do it as slowly as you want
57:18
yeah that's cool so yeah Yeah,
57:20
people head along to Tendinopathy Rehab.
57:24
Remember, tendin is an I-N as well, like the now. It's just stupid English,
57:28
but it's just like tendon.
57:29
I know it's an O-N, but as soon as you stick anything on the end of it,
57:31
it becomes a tendin. I don't know how ridiculous that is.
57:34
Just in case you're struggling to find it. Not everyone knows it.
57:36
So tendinopathyrehab.site and you'll find details of that.
57:40
And yeah, I mean, we never say there's one CPD that everyone should be doing.
57:45
But if you are into tendinopathies then the guests we've
57:48
got on the show is definitely you know you're not going to go far wrong if you
57:51
tap into some of that information and then also if people want to keep in contact
57:56
with you and you do put a load of great information out there you've got instagram
58:00
which is tendinopathy rehab you got facebook which is tendinopathy rehab,
58:06
and then twitter god bless you're still on twitter still putting things on there
58:10
and that's dr pete maliaris which shows how old that account probably is.
58:16
But yes he still managed to get some of the
58:19
first social media account i got actually twitter one yeah that
58:22
was um people people are sort of moving away
58:25
from twitter now aren't they but i still i still
58:28
i still don't mind it twitter oh no it's great it was
58:31
um my guest a couple weeks ago was joe gibson i'm
58:34
not sure if you're familiar with him you probably hopefully are yeah
58:37
and i found her twitter account because she was shoulder geek one which
58:41
kind of was before it was called to be a geek and now i think there's about 120
58:44
geeks of all different things but she was shoulder geek one back in
58:46
2012 or something and i
58:49
told her how many tweets she'd had it was something it was i don't know 475
58:54
000 clicks of send and she was horrified over those years yeah it's crazy how
58:59
much it's crazy yeah quite scary yeah right there well as cecily hislop says
59:04
i think that sums it up nicely as someone who has sporadic achilles tendinopathy this has been so
59:09
useful thank you gents it is kind of cool
59:11
isn't it when you're a clinician i remember when i first ran when i
59:14
first read born to run bless it the book and i
59:18
was in mexico on holiday and i was running along the beach with no shoes on
59:21
hearing the sound in the wind of the indians telling me what to do and yeah
59:26
double achilles tendon opposite when i got back to clinic i'm limping around
59:29
probably like your mate who came into this clinic and i remember my boss saying
59:32
matt you realize you don't have to experience all injuries to treat people but
59:35
it kind of helps because i I learned then,
59:38
you know, it's what it's like for people when you are injured.
59:41
Pro-K sports medicine. Oh, look, who's with us? Andrew McCauley's here.
59:46
And he says, that's the second time we've joined as managers.
59:48
It's becoming a regular thing. Did Peter's course years ago.
59:50
Brilliant and so generous with his time. Top guy.
59:52
Well, coming from Andrew, that's a great piece to know. That's very kind.
59:58
Thank you, Peter, for joining us. I really appreciate it, especially at the really early time.
1:00:02
We're going to be joined next week by a colleague of yours, also in your wonderful
1:00:05
land, your massive land.
1:00:08
So Alison Grimaldi, Dr. Alison Grimaldi is going to be with us,
1:00:11
doing understanding tendinopathies of the hip and
1:00:13
pelvis which is obviously allison's speciality that's gonna be
1:00:16
next week at nine o'clock and then also for your
1:00:19
neck what is it about australian tendons what's is that just
1:00:22
because i don't know i don't know
1:00:25
it must be something in the water it's it's you know it's massive spiders and
1:00:29
tendon geniuses i don't know what's about it is you got bill viscensina yeah
1:00:33
ebony but jill you got yeah it's just a but i think it all jill is probably
1:00:38
to blame for a lot of it because ebony and i came out of her all right okay yeah yeah.
1:00:48
Great so yeah dr ebony will be in she'll be
1:00:51
with us at episode 200 which is may the 28th and managing tendon
1:00:54
pain pain being one of her specialists and so it's going to
1:00:57
be really cool as well so if you can join us live if you listen to this and enjoy it then
1:01:00
listen to the recording then yeah join us live on any
1:01:03
of those dates if you can't and you enjoy the content which is
1:01:06
all all obviously free and it's just from the the kindness of professor
1:01:09
peter maliaris's heart then do kind of
1:01:12
just leave a recording because leave a review i mean it just helps us appear
1:01:16
higher google and everything that peter said tonight will appear higher google
1:01:19
which is just helping our industry everything just what it's all about so do
1:01:23
please do that if you can once again professor peter maliaris thank you so much
1:01:27
for your time mate and uh thank you matt thank you we'll talk again soon see everybody take care.
1:01:32
Music.