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David: Let's talk a little about Aspetar. So, how long have you been in Aspetar now?

Daniel: I've been here almost six years, five and a half years. I came as the senior physiotherapist for athletics in the academy. I was an athlete. I'm a runner now and I've been in this position for like, four years. Since one and a half year ago, something like that, I'm the head physiotherapist that's overlooking all the sports, mainly football, athletics, squash, table tennis. It's keeping me quite busy.

David: I bet it is. Yeah. For sure. So you were an athlete before you were a physio or in your pre-physio days or throughout your career, what was your background?

Daniel: Yeah, throughout. I started when I was 16, 17, and then until ... You never know when you finish really because I was a long distance runner, so you always keep running, you always keep competing you never know if you are really an athlete or you are already an amateur runner.

David: Excellent. So, you still do a bit of running now, then?

Daniel: Yeah, of course. One marathon per year is mandatory, so that keeps me busy and keeps me feeling like an athlete.

David: Yeah, nice. Based on the temperatures that I've experienced in the middle east, you have to getting up pretty early to be getting out for some long runs.

Daniel: Yes. I can never prepare for autumn marathons, I can only prepare spring marathons. So, I train in December, January, February, that's quite good for training but now it's starting to get a little bit hot.

David: Yeah. Short runs very early would be the order of the day, yeah, yeah, excellent and is that where your interest in tendinopathy started, or where did that come up?

Daniel: Yeah. I can recall the first time I heard about tendinopathy because I think it was my first year as a runner, as an athlete I was probably 15 or 16 and I remember one day, I forgot my running shoes and I had to take another shoes, just normal sport shoes and I went for a one hour run and when I came back, I started feeling patellar tendon pain but back then, I was 15 years old, I didn't even know what patellar tendon was. But I started that exact day after a one hour run and it was with me for like four or five months, and then on and off, on and off for like two, three years. So, that was my first contact with tendinopathy and then, I ended up in a doctor ... you know how this is, you go to a doctor, then to a physio, then to another doctor, then you never finished. Then, I ended up in a doctor that told me, "Look, the only thing you need to do is strengthen your quadriceps doing these two exercises daily, 10 sets of 10 repetitions."

So I went home. He looked so convincing that I did it every single day and in like two, three weeks, suddenly the pain disappeared and it was like, "Oh, this is really amazing." Luckily, after a few years, I ended up working with this doctor who is a very well-known orthopedic surgeon and he was one of my mentors if not my real mentor, Dr. [inaudible 00:03:03] in [inaudible 00:03:04] in Spain. I learned so much with him after but I always tell him, "You don't remember but you started mentoring me 10 years ago when I was a young athlete." And then I started getting interested in tendinopathy, of course, being a runner, you're always surrounded by people with Achilles tendinopathy and those kinds of things and then I also hurt myself many times, that's why my interest started.

David: And so, when you look at sort of the journey of tendinopathy over that last ... whenever, since you experienced that when you were 15 or so, and especially over the last few years, especially when you've been working with a whole number and a broad range of different athletes in Doha and Aspetar, how do you think the treatment of tendinopathy has changed over the last few years?

Daniel: I think it's changed quite a lot I still remember one of my first patients when I became a physiotherapist like 15 years ago or 16 years ago. He was an amateur runner who had an Achilles rupture. He had the surgery and after a while he came to me and I still remember the title of treatment I did for him, and he improved. We did ultrasound, laser, all these passive therapies that I still think now, "How did he improve?" I don't really know but, this is what we used to do at that time. If it's electrostimulation, electrostimulation then you go to dry needling, dry needling and it was so much passive therapies and I still remember the first time I heard about eccentrics, it’s out for some protocol. It was probably 2001 or 2002, the first time I heard about it and it sounded like, weird. "Why would this have anything to do with this physiotherapy?" But then the evolution has been really, really quick in the last few years.

I think one of the best things is that, many people around the world is working on this. So, people is fighting to get the best out of each research group or clinicians. So, if you say eccentrics, I will say isometrics, if you say isometrics, I will say heavy slow resistance and that's making everything improved. That's making all of us thinking even farther and trying to be 360 degree views. I think this is the main evolution, is of course the continuum model by Cook and Purdam was a big landmark for everyone because it made us think of this as a continuum, not as a pathology that happens at one point. But then in the treatment, in dealing with the athletes, I think that's the main thing. There's been a lot of publications but then suddenly people have been applying it on a daily basis If I read a paper about eccentrics, then suddenly I want to apply it to my athletes. Which is also a danger, because it never applies to everyone.

David: There's been lots of research coming out and like you mentioned, there's research on eccentrics, isometrics, heavy slow resistance, all those sorts of areas. So, in your sort of day to day practice when you're training athletes, how do you think that's changed or evolved over the last few years specifically?

Daniel: Myself, of course, because as everyone I started dealing with every kind of tendinopathy, amateur athletes, professional athletes, and then sedentary people with tendinopathy. So, dealing with the sedentary people or amateur athletes is quite easy. More or less, anything will work. As long as you load them a little bit, they will improve and you will think you are a great physio they just load it a little bit and they improve. The difficult thing comes when you have to deal with elite athletes and you really have to refine what you do, when you do, and how you do it. Then, is when you realise this is not so simple, not anything works I think, as everyone, this is typical along your career, you start copy-pasting. So, you learn a protocol, you apply then, after a while you realise, "Okay, I am going to start modifying and I will do it my own way." And then, probably you end up merging 1000 things on the way you work and I still believe every clinician is different, and every clinician has to be different not everything works for everyone because of the way we are.

I think one important part of tendinopathy is education. We need to educate the patient on what to do, what not to do, how to do it, and how to deal with pain, how to deal with chronic pain. But there are some clinicians who are not good at education because they do not have very good communicative skills. Others are really good at that. In my own way, I became more, let's say on the education part together with the applied part I started more applying protocols, and then I ended up more listening to the patient, adapting to how things are working on a daily basis, and being very open minded to changing things. If we did this yesterday and you don't feel good, then we change. "What do you think?" Elite athletes are really, really good at that they know their bodies perfectly and they can tell you. I was very lucky to deal with ballet dancers for a while, which are the top, top elite of knowing their own body. So, their feedbacks were really amazing and they were able to tell me, "Why don't we change this angle or put the foot in this position? Or I felt that by doing this I am loading more here."

So that was amazing feedback for me to learn from them, and this is what I started applying later on. Every time, I ask the patient, "How do you feel? Do you feel this is working?" "I don't really feel load in the tendon." "Okay. Do as you think, I want you to feel this. Try it." "Okay. Like this, I feel more load." "Okay. Let's do it like this for you." Probably tomorrow, it will not work for someone else. But I'm more focused on what to get on the target of what I want with the treatment, more than applying the treatment and seeing what happens.

David: Yeah. Great and I think that's a really nice place because there's so much to explore within that and it's great you can experience that, especially with those ballet dancers that were so in touch with what was going on within their body and could come up with suggestions, and you were able to incorporate that into their treatment. So, I want to explore that with you. So, you said that you've got an idea in your head about what you want the patient to feel or experience with that so, tell us a little about that. What is it that you want them to experience?

Daniel: I think one important thing with everyone nowadays, everyone, it's clear that exercises and load management are the gold standard for tendinopathy. Let's make that clear, everyone knows and everything else we do is just an adjunct to that. Great. Knowing that, once we start with the load management of the exercise itself, going to the exercise first, let's talk about the load later, I think one thing we are missing is that the debate has gone too far on the type of exercise we should do, if it's better isometric or concentric or eccentric or slow or fast or heavy or not. One thing we've missed is, it has to be specific to the tendon if you do a squat, a squat can be heavy, can be slow, can be isometric, eccentric, and can be many things.

But it's not specifically for the patellar tendon, in this case. It's an exercise for a whole kinetic chain, or a deadlift, or many other things are very good exercises, obviously loading the tendons but what is really, really effective is loading the tendon. For loading the tendon, you need to isolate the muscle and isolate the joint and do it of course heavy, slow, eccentric, concentric and then, you can start debating on how you do it or the modality of exercise you do but I think one thing we've been missing a long time is stressing that we need to isolate the tendon. Otherwise you don't load the tendon and I think that most of the times the tendon is painful and I remember an athlete I had that he had been isokinetic tests quite regularly on a weekly basis, something like that, to test his strength and his strength weekly was up, down, up, down, up, down. Strength kind of changed that fast. It kind of changed within three days.

It's only how your response to that stimulus is. So, if your tendon is painful, you are going to inhibit your muscle so that whenever you are doing a more complex exercise, if you have a tendon problem, you think you are loading the tendon. But if you are hiding it within the kinetic chain, you are probably not loading the tendon at all so, what we really need is to isolate the tendon. Once you are sure that load is in the tendon, then we can progress that's why I'm really interested in the feedback of the athlete. So, "Are you feeling the load in the tendon? Are you feeling the load in your knee in general? Or are you feeling it in the quadriceps or in the hip or in the ankle or somewhere else?" If they don't feel in the tendon with the most specific rehab exercises, then we have to find a way to really load the tendon and I think anyone who had tendon pain, you really know when the load in the tendon is, it’s where you feel the pain when you jump or when you run or something like that.

David: So what are you hoping they're going to experience? You said you want them to feel the load in the tendon. Are you expecting them to feel some discomfort or are you expecting them to feel stress on the area, or what is it you're saying to patients? Because I'm sure they probably ask you, "I don't know. What do I feel?" So how do you explain it to them about what they should feel in their tendon?

Daniel: I would not necessarily be looking for pain. Obviously, the more acute cases, they can feel or they can report some kind of pain. But I think pain will trigger much easily when you do a fast action, like a jump, like a hop, like running or sprinting, something like that. That's what the patient reports more clearly like pain but doing a focused, isolated exercise, heavy and so on, it's not really pain what they feel they will report some kind of discomfort.

If that tendon is painful, they will report something more similar to discomfort and if that tendon is in a more advanced phase, in a more functional phase, they will just report stress in the area or a tension in the area, not necessarily pain.

David: Imagine that the patient's saying that they're doing some sort of exercise for their patellar tendon, let's pick any exercise, and they say they're feeling it in their quadriceps and not in their tendon. How do you then adapt that exercise or what do you do then? It sounds like you're wanting them to feel it more in the tendon than in the quadriceps, is that right?

Daniel: Yes. I think it's difficult and let's make one thing clear: there is not a tendon and a muscle it's a whole unit and it's very difficult to isolate one thing without the other. There are no exercises for the tendon and exercises for the muscle. Everything loads everything. But it's clear that same as happens with hamstring and leg curl or hamstring or Nordic hamstrings load different parts of the muscle the same can apply for the quadriceps or for the Achilles tendon. You can load distally, let's say playing with the angle the exercise is at with where your center of mass is. So, let's take one example, one exercise I really like to do because it's simple and you can do it anywhere, which is a Spanish squat, just using the belt. A Spanish squat looks quite simple and everyone names it as an exercise I can give you 100 variations within the same exercise. The Spanish squat, depending on how deep you go on the position of your trunk, if you are having extra load like five kilo, within playing with this with some devices, these same five kilo if you put them back here is around 10 kilo just because of the lever arm.

So, if you want to play with where the tension is going in the tendon, there are so many things you can play with apart from repetitions, extended load or speed that we never thought about that specifically, but at the end we've always been doing it because as a clinician, as a physio, what leads you to choose one exercise over other? Because if you have a high jumper, obviously you have clinical reasoning behind what you are doing. It's, "Okay. Let's do this exercise, exercise number one, two, and three."

Okay. That's good for the protocol. But then when I'm dealing with my athlete, obviously I will not apply the same exercise for a table tennis player and for a high jumper and what's my reasoning behind that? That reasoning is never something you write it's something you have in your mind and you say, "Okay. I will choose this exercise because it's more similar to his sports specific task, or because it's loading more the tendon, or because it's more focused on this type of exercise he usually does in training." So, when you try to apply that to the exercises you do, you can also modify that and using the Spanish squat as an example again, you can go deeper you can change the angle of your trunk. So, if you are in a 90, 90 position and you go back with your trunk, the load is being more distally and it's being more to the tendon and if you fix your feet against something, then the load is being much more to the tendon if you are in dorsiflexion, like in a declined board instead of being your feet flat on the ground, you put them against a declined board in dorsiflexion, you are blocking that joint so that the load goes much more to the knee and that's the best way of isolating the exercise in the patellar tendon.

That's one thing that I usually do in my first session if I choose this exercise, I go through this learning process. I don't just put them in the exercise and say, "Do this." "Okay. Let's do it without the declined board. Do you feel the load in your knees?" "Well, a little bit in the quadriceps." "Okay. Let's put the declined board.” Do the same. “You feel it?" "Oh, much more." "Okay. That's why. That's the feeling I want you to feel. From now, we'll start progressing and I always want you to feel this."

David: So, you're looking to load the tendon and find a position that places that load on the tendon where they can feel it specifically rather, than on the muscle. So you play around initially with testing it in just a normal position. For instance, if you've picked that Spanish squat then you've got to play around with the dorsiflexion, blocking them into dorsiflexion with your declined board and then playing around with trunk position as far as if you take them a little bit backwards then you find that tends to load them a bit more distally, you said.

Daniel: Yeah. Those are things that you can play with in the progression. Some athletes will not be able to do the Spanish squat at 30 degrees of knee flexion, so then you start there. But as long as they can progress it's very easy because you don't need to add weights or bars or use 100 exercises to change. Just go a little bit deeper and then you will load like double in your tendon and if you feel it's okay, then go back with your trunk and if we've done all those things, then we can start including some weight and if the weight is comfortable here, then let's put it here. So within the same exercise you have a lot of variations without moving too much, which I think, again, it has one education part if the athlete himself can see that yesterday he couldn't even do 30 degrees and today he's at 90 comfortably, so he feels okay, we are progressing. While, if you change exercise, if you did this one yesterday and do a new one today, okay they feel better, but they don't know if it's because of the exercise or because of other reasons.

David: How do you choose that initial position again? You said, you mentioned 30 compared to 90 is it because they're not actually able to hold it at a position of 90 degrees as opposed to 30? Or because they feel that more in the tendon at 30 degrees rather than 90? What's your starting position choice based on?

Daniel: I think it depends clearly on the athlete tolerance. Some athletes will not even tolerate that exercise at any position, so then you have to start with leg extensions, which is quite a good exercise for the initial phases but I think anyone who has dealt with high level athletes will agree with me that whenever you do let's say the standard progression going from the isolated exercises, the more complex exercises and then plyometrics and so on, you very quickly reach a point in which exercises that were very effective or were really feeling a lot of load last week this week feel really easy. So, there's no point in keeping that exercise why should he keep doing single leg extensions with the same weight or with the maximum weight the machine has if they feel it's not loading? Then we have to progress to something which is let's say more difficult.

That's why there's no initial position for anyone. More or less what I do, which is I think the standard treatment that all of us use is, do a quickly functional assessment. Let them hop, jump, do calf raise or single leg squat or something, just for you to know where they are in this progression. Knowing where they are, you will easily know that, "Okay. With this one I don't even need to do single leg extension." Not all of us have all the machines and all the resources. So at the end, you have to play with whatever you have. So, that's why I like, even if we have Aspire Academy, one of the top high performance center's in the world, we have almost everything, but I love working with simple things. Why? Because not every day the athletes will be in the academy. If they become elite athletes, they will go to another place in which sometimes they don't have everything or, if they are athletes in athletics specifically, you compete in many places you are a cross country runner if you go to run across country, there will be nothing there except a tree.

But you can always attach something to a tree you don't need the leg press machine, you don't need the isokinetic machine. So, I try to make it quite simple for the benefit of the athlete. For my benefit, it's easy. We have many machines, we can use everything but I prefer that the athlete find something useful that he can really use. Because if he uses, then it's effective if he cannot use anywhere else, then it's not effective.

David: You're allowing them to do it no matter where they are or what equipment they've got. It's really easy for them to do it.

Daniel: Yes. I think that makes sense, again, in practice because we attempt to think if you think now of Manchester United, FC Barcelona, you may think, "Okay. They have everything. Look, they have eight physios, they can do with them whatever they want." Look, at the end every place is exactly the same. We can have all the resources, but we never have time. Sometimes, it's much easier to find an exercise that he can do before the warmup on field than letting them come to the clinic because they have to come after training, they are tired, they have recovery, they have a nutrition appointment and they end up not doing it because they have to walk 100 meters.

So, it's easier even at the highest level to find something that is easy to do because they don't have time and coaches and the system will not allow you to spend one hour and a half with one guy for doing treatment, okay but imagine prevention imagine most of the athletes with tendinopathy are competing. They don't stop because they have tendinopathy, like it happens with ACL that you have plenty of time to play with them, whatever you want.

With tendinopathy, most of the times they will be training they will be doing 80 or 90% of the session and you only have a very small window of opportunity to have some input or some feedback. That's why I insist too much and I sometimes talk too much about this isolated exercise and people tend to think, "Okay. But this is in the initial phases. Okay. That's when you are dealing with athletes in which you can do the whole progression or with post-surgery. Okay. Then you start with the beginning isolated, and then you go to the more functional thing." I usually don't insist on plyometrics or those kinds of things because in my mind those athletes are already competing. So they're already doing 150 jumps per session they don't need to come to my session and do another 150 because that will overload them, obviously.

I prefer to, if they are already doing this last functional phase in sport, I only need to complement with the isolated tendon thing because the general strength, they will already be doing it in the gym. So, I only need to complement with some small thing, with whatever they are not doing. It doesn't make sense that we do strength session apart from their strength session that they are already doing, unless they cannot do it and we need to do it because we have the agreement with the FC coach or whatever. But this is why insist too much on isolating the tendon, because this is the only thing they don't do in the normal training scale.

David: Okay. So they're doing their normal strength training session and you're getting them to incorporate their specific tendon loading into that strength training session and then just imagine that they're an athlete and they're performing a few different exercises.

They're doing a leg press and maybe a squat and then you've got them doing Spanish squat for their patella tendon are you looking for them to feel it in their tendon through all those exercises? or you're just going, "Do your regular exercises and we're looking for you to feel that load on the tendon in the specific exercise that you’ve given them," how do you tendinopathy to break it up with them?

Daniel: I think once again it depends on the strategy you follow with different athletes I can tell you two different athletes I had at the same time with patellar tendinopathy. One of them, we were doing specific tendon sessions out of training every single day, sometimes twice a day, because he was very keen on doing specific tendon things. He was a high jumper, he needed his tendon 100% or 110% because of the way the athlete was, he preferred to do specific tendon sessions. With the other athletes, I was not able to pull him out of training to do anything at all. Because he was 100% into doing whatever needed inside training but once training is finished, I'm off, I don't want to do anything extra. So, the strategy has to be different for these two kinds of athletes and I think it's quite common in any team, in any sport that you can never do the same for two different athletes. We know it's written in all the books and so on, but then suddenly one day you come to practice and that happens to you.

So, then you have to find strategies and I think we have to be smart on this and having a team approach and usually, not in every sport, not in every context, but we'll have coaches around and sometimes, the best thing is to have the buy in from the coach. If I can have this athlete to integrate this exercise within training, I'm more than happy I only want him to do it I don't need him to do it under my supervision. I would tell the coach, "Look, why don't you include this Spanish squat or single extension or calf raise or seated calf raise, whatever it is, include it in your normal routine you have 12 exercises from now on, we'll have 14. Include these two." We don't even need to tell him this is for his tendon it's just exercises he's doing and then you will focus on different exercises.

In the squat, you will focus on technique. In the bench press, you will focus on the load, whatever and whenever this exercise comes, you need to tell him he needs to feel the load in the tendon or in the quadriceps or whatever we are looking for, or the speed, or the hops, or box jumps or something. So for some athletes, it really works well like this. Others, themselves, they need to do something specific for the tendon because they feel like it's like one thing is training, the other thing is real. So, I think it's up to us to be quite flexible on this otherwise, the athlete always has to lead this process. If you don't allow him to lead the process and you lead it, you lose him after a while because it's very common that after a good intervention, imagine we do a good intervention, we have opportunities to manage the load and decrease the load and don't play these two games and so on, it will improve.

After two weeks, if they improve, they will never come back to do the exercises again because they feel good. Even if you convince them that this is a program that you need to follow for 16 weeks or whatever you want, but whenever they are not leading the program and they feel good, they will abandon the exercises because it's boring. "I don't need to spend here 30 minutes every day doing this, for what? I don't feel any benefit. I'm okay."

David: And how do you get the patient to lead the exercise. Tell about some ways that you've found to get patients to do that and what that entails. Daniel: I think for this again it's on a case to case basis but you have to approach them or you have to, as I said, let them think they lead the program, they can choose the exercises, they can choose the way they do it, because you allow them to have feedback. You constantly tell them, "How do you feel this exercise?" "Okay. Today felt really good." "Okay. You want to do it again?" "Yeah. I prefer to do this one." "Okay. What if we try today this new one." "No, I don't feel today like ..." "Okay. Today, I let you choose." Then, tomorrow I will find another window I always say that I need to find a window that is open, that single day. So, if today every window is open, then I will lead the program. I will say, "We'll do this, this, this, and this." Some other days, the windows are not open because they lost the match yesterday, he was not a lineup player, or he didn't score that goal that he should. So, today probably every window is closed and you kind of have to be a little bit quiet, don't overreact to things. But most of times I find the window by the feedback I give to them and they give to me.

For example, let's talk about how we monitor it by doing the declined squat daily so that they can score the pain, or by scoring the pain they feel in the morning when they wake up in the Achilles tendon. So, every morning they will report to me so that I will sometimes show the graphs that I do and say, "Look, you remember? We loaded yesterday and the day before. Today, the pain is less. So, let's try next time to load the same way and see if the pain decreases again." So if that happens, not necessarily happens, but this is our expertise, to manage the information as we want.

If that happens again, then you will show him again and you will say, "Every time we do this type of exercises or we do this after training or before training or whatever it is, you improve. Let's try to do it again." And I had one of my athletes telling me that doing exercises was like taking anti-inflammatories. He used to take anti-inflammatories before and he found that taking anti-inflammatories decreased his pain. Makes sense. Now, he found that doing these kinds of exercises this way decreased his pain. So, he was like okay, I don't need to convince him. He's already convinced by himself.

David: Well, that's what you want him to feel.

Daniel: Yeah.

David: And so there's a couple things I want to explore within that because you mentioned some really good points so I want to talk to you about how you go through identifying which level of exercises is right to start them with or which one's appropriate. But first off, you mentioned earlier and I want to come back to a point, you were talking about education and you find education's a really important aspect within their treatment. So can you give you me a little bit of an idea about sort of the education your provide your patient with when they come in on their initial session, the key aspects that you want them to take home?

Daniel: I think this is probably the key for successful management in the future, not only for tendinopathy, probably for everything, is the first session. If you are dealing with your athlete, let's say you are the team physio of any team or federation or whatever, probably this first consultation sometimes does not happen because, you are with them on a daily basis and you are discovering things and you never have time to have consultation sitting on a chair in front of your patient and so on. I still encourage you to do that because that breaks a barrier. Whenever you have an athlete, you are used to dealing with him on a daily basis in the dressing room and so on. Sometimes, you need to sit with him in front of the table saying, "I am the physio, you are the athlete, and we will discuss this." And that kind of breaks this pattern you have when you are dealing with athletes on a daily basis that seems that you never have time to do these things. I encourage people to do that and if it's an external athlete, that happens by itself.

So in this first session, I usually focus on exploring the history of this injury. This is from first degree in university, they teach us to do this. This is nothing new that I've discovered. But it's important to focus on this. Why? Because most of the time, we don't have an exciting event for the tendinopathy, it just happens progressively. So if you don't see it and analyse, you don't realise, even when you are an athlete that example I put before, when I was a kid and put those shoes and so on, I didn't realise that day. I realised a few days later. So, you sometimes need to sit, in this case you need to sit with someone that can explain to you as a patient what's happening. So, one of the most important things for me with tendinopathy is to look at the history of what has happened and the athletes, by default they will tell you, "No. I didn't do anything yesterday” or “I didn't do anything last two days." Look, tendinopathy doesn't happen in days it doesn't probably happen in weeks, it's probably happening within months and sometimes years.

So, it's sometimes important to have a paper and if it's a patient that requests a consultation because we work in a clinic and you book and appointment and I know he reports his tendinopathy and I know he's an athlete, I will tell him to bring his training diary or his training history or to prepare it even if it's in mind, because that's important information for me. You may find people that tell you, "No. I've been running normally." "And how about your volume? Did you have any recent spike in volume or something?" "No, no." "How many kilometers per week you do for a runner?" "I do 80." "And last week?" "85." And you don't find anything but you really need to go deep because you might find people that didn't run at all for two years. They started running three months ago and then for them nothing changed because they'd been running for three months and they will report that they haven't changed anything in the last month.

Of course they didn't change anything in the last month. But if you look at the whole picture of the last three years, everything changed. So this is for me the main educational part, because once they realise about this, whatever it is, volume, intensity, "I changed my shoes, I started running in a different court, or I didn't play games and suddenly we have three games in the same week," whatever, we have to find I know especially sport, it's a very complex system, it has so many corners and things and factors that can affect. But I more let's say didactically usually divide it in external factors and internal factors.

Internal factors obviously are those that are age, metabolic diseases, whatever that you cannot change. External factors are those that you can change or change by themselves. So, I start sometimes with a paper, I do two columns and I start asking them and then I start writing and at the end of the session I show them the paper and I say, "Look, with have this bunch of factors that can affect here. Most likely, it's related to this. Does that make sense to you?" "Oh yes, maybe it makes sense”. So, whenever you do that in the first session, you don't need to convince them too much later on because they already realise the whole picture and then you have their buy in for doing the exercises or commit to the program.

David: So, you're looking overall at if there's been any spikes in training load over the last ... it could be last months or years or whatever that then you can relate it back to and say, "Your tendinopathy has developed but if you look back, you'll see why there was an overload in the tendon from this spike in training at this point."

Daniel: Yes. And most of the times, I don't know if that's the main reason for the tendinopathy, but that's a very important reason. I usually say that you can never know what the main reason from an injury is, but you can guess sport injuries most of the time are because of sports. You can have other factors, but the triggering factor most of the time is in sports and I usually say that the main reason for divorce is marriage. It cannot happen without marriage. So, sport injuries most of the times cannot happen without sports. So, our main focus has to go to sports and then of course, there are 100 other factors that you can also explore but if you're dealing with an athlete, don't focus on stupid things first. Go to the main things first and explore the stupid things at the end.

David: And so what about if your athlete doesn't have a training diary.

Daniel: That happens most of the time I would say in team sports. Let's make this difference. Individual athletes are really very, very specific, very committed. Runners, even I would say, more amateur runners than professional runners have a training diary and so on. But you have to adapt to each sport and obviously, we are physiotherapists. I know a lot of athletics and many other sports but I don't know about all sports. So, I try to adapt with how they report things. I don't know and I haven't dealt too much with swimming for example but then I would ask the athlete or the coach if he's available, "How are you training?" I would try to understand how these things are.

I was dealing with ballet dancers I have no idea about ballet. So, the first thing I did was go and spend one afternoon with them seeing what they do because I don't understand ballet so, I was able to catch a little bit, general idea so that then I can focus on what to ask, what to look for and if not, ask directly the athlete.

As I said, in team sports it's more difficult because even it's quite difficult to know what their specific load is but you can always get some ideas and the important thing is what you are looking for. If you are looking for spikes in load, probably obviously a team sports athlete will not know how many kilometers he runs in a basketball match or how many jumps or changes of direction. But if you are looking for load you can start asking, "How many games are you playing per week? At what point are you in the league right now? How was your preseason? Are you playing for two teams at the same time?" Because with youth athletes, it sometimes happens. They are playing for under 18 and for senior team. Then there it is. So, it obviously depends on each sport and each context, but the important thing is what information you are looking for.

David: You mentioned they're also within the education, so you're looking at those factors that might have led up to them developing the tendinopathy and identifying their intrinsic factors. So, they could be any of their health factors or that sort of thing and then extrinsic, looking at their training load and you mentioned there you demonstrate those factors, or you show them on a piece of paper, the extrinsic and intrinsic factors that might be impacting their tendinopathy and that makes up part of your education there about identifying those factors and how it's led to it. What else do you find in that education within that initial session is really important?

Daniel: I think one key thing that everyone who has sustained tendinopathy as I did and many of us did is understanding how pain works, because it doesn't have a let's call it normal pattern for a non-health practitioner person. You usually tend to think that this is painful if I do something, it will stop being painful or the typical thing that we are told by the patients, "I will not run again until it stops being painful." And I always say, "That will never happen. Eventually, it will become painful again." So, I think that most of the times if not all the times athletes and people in general are coming to us because of pain. That's the leading reason for consultation. So, that's what they want to solve. They are not worried about the function or the dorsiflexion or whatever, that's for us. That's our language. They want solutions and the solutions are pain.

This is the only thing they're worried about and this is the reason why sometimes I am worried about applying adjuncts at the very beginning, because you don't educate them in the long term.

If I give you anti-inflammatories or corticosteroid injections and so on, great, I know that will solve the pain and you think it will solve the problem, but I know it won't. So, that's why the main part of education for me is teaching them how pain works in tendinopathy and that has a few very simple rules.

Number one, we all know it's a delayed pain. So, I tend to stress too much in the very first few days, I don't really care if it's painful when we do the exercises or when you train or whatever I don't care. I'm worried about how it is tomorrow or the day after tomorrow, and let's see if we find the pattern. So, do whatever you want today, but I want you to report to me tomorrow. If you come tomorrow and you say, "I'm okay," then that's okay. So that's a very good educational point they start thinking not on the moment but, on what can happen later and that's really important because that changes their whole focus on, "I shouldn't run if I feel pain or I should run if I don't feel pain." So, that changes the focus to something else, to function. I want you to function. Pain is another thing that we'll discuss tomorrow and then based on that they have to learn how to deal with that and how to find patterns. Some people have a delayed response of hours, some others will have a couple of days. That's why monitoring is so important, because they learn how themselves behave to pain but then I try to think, and again there are different profiles of patients, some people I will educate too much about that because, they are this typical profile of people that they don't care. So, I have to remind them all the time. Some other people will have a mathematic mind and they will start playing with the numbers. "Yesterday was 3.5, yesterday I did 15 repetitions, and today is 3.7." To those people I say completely the opposite. "Look, don't try to find any pattern because most of the times pain will go up and down and we have no idea why I don't have any idea and you will not have any idea.

So, don't try to focus too much on the detail, look at the overall picture and say, “We have two ways of improving: having less pain doing the same or having the same pain doing more."

So, "How are you now compared to two weeks ago? Two weeks ago you were not able to run 10 minutes. Now, you are running 60 minutes. Do feel the same pain?" "Yeah. Exactly the same." "Yeah. But you are running six times more, so obviously you are better." So, that's the main part of education around tendinopathy, goes around education about the pain.

David: Right. Anything else that you like to include in that initial education phase?

Daniel: I would say those two things. Focusing on how pain behaves and why you have to monitor this delayed pain response and, so on and with those two things, I can open that window to enter the program and to really commit to the program or to have some input in him.

David: And how do you go about measuring the athlete's pain that next day or in the subsequent days? So, let's just imagine that they either have some pain on waking or they don't or whatever. Do you tell them to perform a test, or do you just tell them to tell you how it is when the wake up, or what's your sort of go to when it comes to measuring it?

Daniel: I think the standard provocative tests that we know are quite good. So, for Achilles, we use the morning pain or morning stiffness as a marker that is, for me I think, is quite relevant. For patellar tendon we use the declined single leg squat for hamstrings, we use the single leg bridge. So, there are some standard tests that are quite good but once again, when we go to the competitive athlete or the high level athletes, sometimes those tests will not be enough. Probably, the morning stiffness for the Achilles is good for everyone but sometimes we have to go one step more. Think with a high jumper let's say, patellar tendinopathy a guy that is already jumping two meters, 30 centimeters and doing crazy things in the gym and plyometrics, doing a single leg declined squat sometimes doesn’t trigger the pain, he needs something else. So, you need to adapt to each level also with the provocative tests.

So, at the very beginning or when the tendinopathy is at an early stage, those tests are more than enough for elite athletes and for sedentary people. That's not the difference but whenever you are in a more advanced phase, you need really to provoke the pain and to provoke the pain you have to adapt to each athlete. So, sometimes it will be a single leg hop. If single leg hop is not even enough or doesn't trigger the pain but the athlete still feels the pain in training, then you have to look for a more plyometric activity, drop jump or jumps over hurdles on one leg or adapting to the athlete. For the Achilles tendon, as I said, I think it's quite reliable, the morning stiffness, because it warms up quite easily and if you assess the athlete at 6:00 PM, most likely there will not be any pain even if he is doing single leg calf raises or hops or whatever, but you can also use for the Achilles the minutes to warm up once you start the training. Some people find that useful. It’s, "Okay. I'm feeling okay. Morning was more or less okay or it doesn't change," but it's a very important marker for me, how long does it take to warm up when I start? It takes five minutes until I feel comfortable or it takes 15 minutes or in one minute it's gone? So that's also an important marker.

David: Let's imagine you've got to tell a tendinopathy patient and then you're looking at them and trying to identify what the starting level of exercises are for them and you mentioned there before that if someone's capable of doing something more loaded, like for instance the Spanish squat, then you'll tend to avoid ... you don't go straight to a single leg extension they're not going to get much benefit out of it. So, how do you go about identifying what the right level of exercise level is for them initially?

Daniel: I think you have two ways of doing it. Thinking about the standard progression that Jill Cook, Ebonie Rio, all these groups have designed this very nice progression, isometric, concentric, eccentric, energy storage and release and so on. That's one way.

Another let's say more practical way is how an exercise stresses more a tendon than another one without being isometric or concentric so obviously, Spanish squat is isolating a lot for patellar tendon, single leg squat also, but doesn't provoke so much load because of one very simple thing, that the tendon will struggle when it's under maximal tension isolated in a lengthened position. If you have those three things and you have an exercise that can have a maximal load in a lengthened position in an isolated way, then you are probably loading it maximally. So, with those three parameters and many others you can also play and see where you can start.

Obviously, if you think about single extension, if you do isometric single extension at zero degrees, it's less load for a tendon than at 30 degrees. As I said before, they are not exactly described as such, but clinical reasoning tells you, that makes sense. So that's one way of testing. I know more or less that the single leg extension is less load, that the Spanish squat two legs is less load than one leg. Single leg press is probably in between those two. But the problem with single leg press is that you are using some other elements of the kinetic chain so I'm not sure how much load is going to the tendon. Quite a lot if it's heavy, but I cannot assure everything's going to the tendon and he's not compensating with the glute or with the calf or with something else.

So, that's why I think for patellar tendon single leg extension and Spanish squat are very good ways of isolating and knowing more or less where you are, and another sign is if there is shaking in the muscle. Some people, if I test a single leg extension and this one thing I do in the first assessment doesn't need anything, I tell him to sit down in the bench. I try to resist single leg extension and if he is pushing like crazy, okay, he is more or less capable. Some people is already shaking by doing that so I know where they are. I know if they're shaking with my manual resistance I don't need to go to the Spanish squat. So, I can start with single leg extension combining with Spanish squat but in an isometric way, in less degrees, with two legs or without load. So, I think one mistake most of us have done or most people do is thinking of this as a progression. "Once I do this, once I tick this box I go to the next one, then I go to the next one, then I go to the next one."

In reality, it doesn't happen like that. You are combining everything all the time with priority on some areas and not so much priority on other areas because you cannot have a guy, let's talk about a jumper, you cannot have a jumper without jumping for 12 weeks just because you need to progress the whole way. So, you need to combine the isometrics and your exercises with some kind of jumping, probably low load jumping, but you need to combine both and if you think about how training programs work, are exactly the same. If you need to work on endurance or on aerobic capacity, doesn't mean you only do that you do many other things, but the priority's in that part.

David: When you're looking at someone and you're using your manual muscle test, say with a leg extension, and then you're saying they're either shaking, so you're going, "All right. Well, they're going to need to do something along the leg extension line," would you run everyone through a test to see how they go with a leg extension first or do you just go, "If they're not shaking, I'm going to do a manual muscle test. We're going to go to a two-legged Spanish squat."? Or how do you identify there which one to start with?

Daniel: Just to make it easier, I do a very simple progression. So, first one would be that one, sit down, push, that feels okay, I test different angles, concentric, eccentric. Regardless of the result, I would usually progress to the other test. "Stand up. Do some hops, two leg hops. How does it feel and how does it look?" Because it's not only quantity of pain, it's quality of the movement. Then single leg hop, natural hop. After that, deep, so let's say a squat and jump, two legs. Then, squat jump, single leg. Then drop jump, then single hops for distance, single leg hops for height and then with all the six or seven tests that you can perform in around 40 seconds, more or less you get an overview of where you are with an elite athlete and so on, then you may have to go to the specific things because most of time they will be able to do most of those things but they only feel pain when they land, a basketball player. "When I go for a rebound, then I feel when landing." So, then you go for specific things.

But as a general overview, within a minute you can do that progression. Single leg resisted, different angles, then natural hops, two legs, one leg, squat jumps, two legs, one leg, and then single hops for distance and for height and more or less you will get where you are if someone was already shaking in the resisted single leg, most likely he will not be able to do the jumps. But sometimes that happens and I've found many cases like that. They are shaking but they can do the jumps and you say, "How can this be?" Most of the time, it's because they are compensating, and they are doing the jumps because the kinetic chain is absorbing somewhere else. So, with that guy, it will be very clear that I need to address strength much more than the kinetic chain, or I will address the kinetic chain later because he’s failing with the very, very basics.

With the other type that they can perform all the strength things easily but they are struggling with the jumps, then I need to focus on the plyometric work and on the technique on the kinetic chain and so on. So, that's why I think this one minute assessment is quite useful, because again, you don't need a lot of technology, it's not a very specific thing but it gives you an overview of where you are and then knowing where you are, you can go for full assessment in that.

David: So, you mentioned there that you're looking at identifying with your manual muscle tests and your resisted, say, knee extension in this case, and then you're moving into your double leg and single leg jumps and hops and those sort of things. So, you're saying if they're getting to the more advanced levels like a squat jump or that sort of thing on a single leg, then you're going to be looking to start your exercise program up more at that plyometric end, is that what you're saying?

Daniel: Mm-hmm (affirmative). But again, not necessarily that, because remember, I said that some athletes are competing. He might have competed yesterday and doing his personal best, but he still has pain. So, I know he's struggling with this last part because he can do everything, he can do the gym and so on he only feels the pain when performing maximal jumps or when doing a lot of jumps. So, I know that the problem can be up there, let's say. He may still need some basic strength and so on, we can assess later but the problem in that case would lead me to think when I split those two things with intrinsic factors and extrinsic factors, that can lead me to think that the problem is more the load.

Maybe he has been jumping too much in the last two weeks and the problem is solved just by changing a few things in the changing program or by talking to the coach and saying, "Look, we've started having this problem have you changed anything in your technique? Is there anything you have changed in terms of the surface you're training on or something? Because he looks quite okay, but the problem is at maximal intensity. So, he's started having this something, but everything else looks okay. What do you think?" So, I always say that at that high, high levels, most of the opinions have to come from the coach and from the athlete. They will give you the best insights of, "Yeah, of course. We changed the approach, technique for the jump last week." Then, okay, that's solved.

David: And so when you're looking at them in that sort of intermediate phase, and I guess with all these tests you're looking for reproduction of pain, is that right?

Daniel: Mm-hmm (affirmative).

David: So let's just say you reproduce their pain with a single leg hop for instance. So then, you're going, "Okay. They didn't shake throughout their manual muscle test. They didn't get any pain with the double leg hop. They got some with a single leg hop." So would you then say, "Okay. We're going to start with the ..." Is that your indication, the Spanish squat is likely to be a good starting point for them, or where do you start with that one? Daniel: Then, if that's the case, I need to know if it's a problem of energy absorption, which sometimes happen when you do the leg hops. It might be a problem with the ankle, with the hip, with the whole kinetic chain and it might be much more complex than the tendon itself. That doesn't necessarily tell me where to start for me, there's never a point to start it's more or less… it gives me an idea of what's the priority. So if I find that, then what I would do is would compare left and right and then I would go farther for a strength test, whatever it is, because it might be a strength problem, it might be strength endurance. So, I would tell him to hop as many times as possible with the left and with the right and find if there is a big difference, he gets fatigued after the eighth repetition compared to the 25th repetition on the contralateral leg. Then, I might think that it's not only the pain, it's the strength of the muscle.

Then, my priority would go for that and then, depending on how the athlete is, if he is already training, competing, and so on, then as I said, I try to look overall at the whole program. What's he doing in the gym? What's he doing in the training? And how can I complement that with my intervention? If that's the case that he needs specifically tendon exercises and so on, then I would start with whatever the exercise It can be leg press, if the kinetic chain is more important it can be isolated for the tendon, and then I would go for the seated calf raise for the Achilles or the Spanish squat for the patellar tendon. Then, something as simple as see how it goes. In the first day, you always have to start from scratch. So, I would say something standard like, "Okay. Let's do these exercises. Let's do overall five or six sets of several exercises, eight or 10 repetitions at 80%, something like that, and see how it goes. How do you feel tomorrow?" "Really hard. I feel DOMS in my quadriceps or my calf and so on." "Okay. Then probably that's a little bit too much, or this is the load that we are dealing with."

If the next day he comes and says, "I feel okay. I don't really feel like we loaded anything," then I will push a little bit more. I think we're always looking for this magic recipe of how many sets of how many reps of which exercise I need to do or to start with or to progress to and reality never works like that.

Every day is different, and every athlete is different and I just need one day to start with whatever, trying it not to be too much for that moment and then it will take three, four days, sometimes a week to adjust and say, "Okay. It was too much or it was not enough." And once you more or less find what the proper stimulus is because it doesn't trigger the pain the day after, he feels a nice stimulus in the tendon or in the muscle but he can still perform, then we are at the point that we need and from there we'll progress.

David: And how do you decide if you're going to start with some sort of isometric exercise or your concentric, eccentric, or how do you figure out that starting point there?

Daniel: I think it's a never ending debate about the type of muscle contraction, what's the best one. I tend to think more about the magnitude of the load, so the total load and I some years ago, I asked myself one question. It's, "How many seconds in isometric for this exercise are the same load to the tendon compared to this eccentric exercise?" So, "How much total load I need to apply to a tendon to have a minimum effective dose?" And I think that's the key and I think that's one thing we need to change in our minds, is we need to apply a high load magnitude to the tendon. The tendon is known to adapt to slow loads, to heavy loads, and to sustained loads.

Why? Because when you do a very fast exercise, the load is absorbed by many structures. When you do a slow one, you pull and you keep pulling all the time, you are sure the tendon is holding that load and you are provoking that stimulus to have the adaptation in the tendon. The key is how much you should do and how you should do it. There are many studies already discussing this, that the key is the magnitude of the load. The tendon doesn't know if he is doing an eccentric or concentric or whatever. Put it in a lengthened position, load it heavy, and maintain it, and then you are sure you are provoking a stimulus there that will be really effective. Where to start this for me is a matter of that it's a matter of overall how much load I put to this guy because sometimes I think, "Look. We have a guy here who is a marathon runner.

He is having like a million impacts against the ground, two times his body weight, and then I'm telling him to do three sets of 10 repetitions of calf raise."

That's nothing. It's like doing biceps femoris with a bottle of water, you'll never get stronger. The total load that you apply is much more important than the type of exercise you do but as I said, the key thing, the reason why I started thinking about all these things is mainly because in sport we never have time. So, you really have to apply as much possible in the less amount of time. So, sometimes you have 10 minutes with this athlete you cannot stay doing seven sets of 12 repetitions to this exercise. Then, I need to find an exercise that loads the tendon much more in less time and less repetitions, so that my magnitude of load is the same as doing 25 different exercises.

David: When you're looking to try and identify the right load or magnitude of load, you said there you're looking for a high load and for that to be a manageable time within their training session or whatever. So, would you tend to base it on how much time they have? Obviously, you're looking to find a starting point and to then build it from there and identify, "Is this the right load for him right now?" and check out what the response is over the coming days and weeks and that sort of thing. So, it sounds like you're identifying, if there's someone that does a lot of steps and a lot of high load, then you're looking to probably start them with a reasonable … and they can cope with that in your assessment session without reproducing their pain. If they're getting to a medium, reasonable amount then you're loading them up a fair bit then. Is that right?

Daniel: Yes. Yes. Part of the assessment is that and sometimes I will look for, let's call it assessment first training session, that is a little bit heavy for what they expected. They sometimes expect to come and do three sets of 10 repetitions of whatever exercise. Then, I will go for something really heavy, just again going back to the education part. First, because I want to know how this tendon responds for myself but, then I want them to understand that "Look, this is not going to be a joke. You are not coming here or I am not going to prescribe you three exercises and finish. No, this is going to be heavy, you need to work really hard and to load that tendon, we need to go really, really heavy." So, that session I will probably go, depending on the case, if it's a very, very acute case then I will not go crazy with them. But if it's this more typical athlete that keeps training, he keeps doing everything, I will try to estimate where his threshold will be and go a little bit above to see how the tendon responds.

So, I'm not worried if the first day they have a spike the day after in pain and they say, "Today, felt more painful and I feel DOMS." Okay. Then, we know where we are and I know how much I can push you because as I said, you never have time. We cannot be testing every day two reps more to see if that creates some pain. No, we have to go straight to the point we cannot be one week here doing ups and down and see how it goes.

David: Do you have an example? So, do you have like a recent patellar tendinopathy patient, you can just give us a bit of an idea about what you found and their objective and then how you started their exercises?

Daniel: Yeah. I will give you two examples, one for the patellar, one for the Achilles, which are let's say the most common, or at least the most common I deal with. For the patellar tendon, let's talk about the jumper that is jumping, he's coming from a competition season and he keeps complaining of the same thing he was complaining before and comes for assessment for the patellar tendon you expect a guy that will be able to do everything and only feel some pain in the hops and then, you find a guy that is shaking in the first resisted single leg extension. He can do some things and you can clearly see there are some compensations there and he's able to jump really good but he is not loading the tendon. So, my thinking at that moment is we need to load the tendon specifically because he needs some kind of reconnection between the brain and the tendon.

Sometimes, when you've been feeling pain for such a long time and you found your way to compensate, then it's very difficult to load the tendon because you don't know where the tendon is and what the tendon does, or what the quadriceps does because you learned to do it the other way.

Then, I would specially go for specific exercises. In this case, I started with single leg extension. Actually, we had to start it manually because even with the 10 kilo in the leg extension machine, he couldn't do it. It sounds crazy for someone who is already jumping. So, I started with something like probably, I don't remember, three sets of 10 repetitions, something like that, because he was already shaking and then some isometric wall squats because he could not tolerate the Spanish squat, the belt. He could not even bear his weight there. Then, you go for the wall squat. That is less specific to the tendon, but in this case that is very, very basic. We start and we do probably three sets of 20 seconds, and it was already too much. What happens is that's also kind of a diagnostic thing. This is one of the debates that has been with isometrics and if they are effective or not for pain, blah, blah, blah. I'm not entering that debate.

But I found quite useful that people who is in this situation and suddenly improve a lot, so within three days they are not shaking, they can load weight and do that very easily, then clearly, we were not dealing with a lack of strength. We were dealing with inhibition. Strength, you cannot gain it in three days. Inhibition, you can recover it quite easily. So, you start with that thing and I said, "Three sets of 8, 10 repetitions, as long as with a heavy weight." Weights always have to be heavy for that moment. That moment, heavy might be five kilo, but he needs to feel really like he is doing something 80, 90%. 80-90% is not easy for some people. I usually talk about, "How many reps could you do? So, let's start. Let's continue. You are doing eight repetitions now. Okay, how many more you could do with this weight?" "Maximum, three more." "Okay, then stop here. We are working around 80%."

And sometimes, when I prescribe, when I send the program I put, "Four sets of eight repetitions, [10]." That means four sets of eight with the feeling that you could do maximum 10. That's quite simple and quite easy for the athletes, forming that principle, I would start with something near 80, 90% at the very beginning. Around six exercises. You can vary the exercises but I'm not a very big friend of doing a lot of exercises athletes prefer to know if they progress within one or two exercises and see how it goes with those. So, "Yesterday, I couldn't hold a wall squat for 10 seconds and today I can do 20." So, that would be a first assessment, and then that would give me an idea and then the day after or whenever you see the athlete again, then you test again the same and you will see where he is so, that we can progress either with other exercise that is heavier or with the same exercise, extending the reps or the weight or whatever.

And the other example for the Achilles tendon, for me the most effective way to load the Achilles tendon is the seated calf raise, because standing calf raise, obviously double leg you never know what he is doing with that Achilles and even single legs, there are so many ways of compensating that movement without loading the tendon but I am not very sure is the best assessment for the first day. Whenever they are trained and they know how to do it, it's a great exercise. You can load it, you can do many things. But for the first day, there are many ways of compensating a single leg calf raise but whenever you are sitting and you have to do a seated calf raise, even if it's double leg, it is really, really heavy for the tendon. So, you will really find where they are and I remember one case, same, a runner over running long distance doing normal training. He couldn't do three sets of six repetitions of seated calf raise with 15 kilo because that was incredibly heavy. That's why it's important the first day to isolate to know that you are really testing the tendon otherwise, if you test the single leg press you don't know what you are testing.

David: Coming back to the patellar tendinopathy patient, initially you had to start with some manual resisted leg extensions and then you also added in some wall squats, which sounded like he was holding for…

Daniel: 20 seconds.

David: ... yeah, and doing a few sets of those, he could progress how long he could hold the wall squats for?

Daniel: One thing that happens with the isometrics is that it followed too much probably these long isometrics, 45 seconds and so on. Number one, sometimes the athletes find it really boring, if you think what is being 45 seconds sitting like this or doing an exercise without doing an anything, It loses its effectivity just because of finding it boring because you can concentrate for 10 seconds on doing a maximal contraction. But after 40 seconds, you will disconnect and you are probably, again, loading somewhere else or not focusing on the exercise. Even if it's very effective by being long, I prefer with the athletes, and this is very important with the elite athletes or the athletes, to progress with weight or with a more difficult exercise so that I can have them 100% concentrated for 15 or 20 seconds or even 10 seconds better than sitting there for 45 seconds doing nothing. Because very soon, they will find that very easily and they will ask for more they will say, "Okay. I can be here for 45 seconds or two minutes if you want," but it's not really effective, I prefer to do something heavier so that you can easily go to the Spanish squat and then that's nothing to do with the wall squat, that will be heavy.

And then, within that exercise they can do those variations I told you. We start in 20, 30 degrees and you cannot do anymore but then, we can progress even in the same session. The first exercise can be very tough at 30 degrees but the second one, 30 degrees, you find it easy, you can go a little bit deeper, or you can play with the trunk or in the third one I can give you some extra weight. The important thing is don't stick to the exercises as we think. Try to think of what is effective for the tendon in each moment and of course it's not the same at the beginning of the session and at the end. It needs to be an effective dose, and it's not the same three weeks ago than today. That's why the protocols sometimes fail, because they fail to adjust to these daily variations.

David: And so, if you go this guy and he progressed over the period of a week and then you were like, "All right, we're going to start you with some Spanish squats," and he could do 30 degrees, how do you find out what his level is at that 30 degrees? You're saying, "Okay, can you hold it?" or are you just saying, "Let's go down to 30 degrees and back up again," or how are you finding the right level for him on that day?

Daniel: I think one thing I try to do, once again it has some part of education, is teach them or focusing on the movement quality, on the quality of the exercise because if you tell someone to do a set of 30 seconds or eight repetitions of any exercise, they are focusing on doing eight repetitions and they don't care how they do the last two, if the quality is very poor or if it's very easy and they are not even focusing on the exercise. I don't mind saying someone to do three sets of six repetitions of a very heavy exercise, and then by the second one saying, "Look, let's do only four because I can clearly see that the last two are useless because you are loading somewhere else or you lost the focus." So, we don't have to be afraid of doing that.

That's why it's important when you are on top of the athlete, and that we are privileged to have that when we are with the athletes. It's more difficult when you have to prescribe someone in those cases, education is even more important.

If you find the repetitions I prescribed you or the duration I prescribed you are really struggling at the end or you don't feel it, that's why it's important in these first sessions to tell them to feel it in the tendon or to feel it somewhere that you want them to feel because if after three sets you feel you are working with the glutes, then obviously this was not effective since a long time ago. So, adjust it until you feel the tendon is really being loaded and whenever you start losing the quality or the isolation, then stop it, don't worry.

David: And how do you decide if you're going to get them to hold or you're going to add weight or whatever? So, let's just say they're going, "All right." They've done Spanish squats at 30 degrees and they're going well, then how do you decide? Do you say to the athlete, "Would you like to load it up more or would you like to hold it?"? Or how do you decide what the next progression is?

Daniel: I think it's difficult to have a magic recipe or even a recipe if it's not magic but I think we have to think about this total load magnitude I was discussing before. Regardless of what you add, repetitions, extra weight, speed of the exercise or you change the position, the important thing is if we were able to have a device in our tendons that tells us how many Newtons or how much load they are sustaining at each moment, ideally what I would want is that at the end of this session you have had as much load as possible. If we can get that by doing 35 repetitions, that's okay. If we can do that by doing two repetitions of a very heavy exercise, I've saved some time and probably the stimulus is more powerful. Think about any strength exercise. A lot of studies are saying that exercises, for strength I'm meaning now, don't need to be very heavy to be effective. You can still get some decent effects with 30% loads and with 50% loads. You just need more repetitions and a proper stimulus.

With tendons, I think the same principle applies. We just need it to be specific to the tendon, heavy, and so on. If you have time to do a lot of repetitions or those lot of repetitions apply more to the sport your athlete does, because obviously you don't deal the same with a marathon runner than with a baseball player because they are very different actions, so probably for the marathon runner you would go more for the lot of repetitions mindset more than for the very heavy thing. But I think both things are effective and both things you can work on them but, once again, we go to the same point. It's, "How much time do you have to work on an effective dose?" Because if for having an effective dose with an exercise you need two hours of work, okay, then it probably will be effective but athletes will not want to come tomorrow.

David: Beautiful. And I think that's a really great place to wrap it up. You've really got our thought processes going about how we can actually load tendons up and how we can apply our clinical reasoning to different patients and test and find the right load for each one of them that's in front of us and think about how to find the right load and the right exercises rather than just going on a sort of recipe based approach, so I really like that.

Daniel: I'm really sorry, because sometimes people expect a recipe, even if it's small. But I really, really believe it doesn't exist. So, I think it's much better if we start changing our mindsets for this and making ourselves think, "How can I improve this? How can I optimise how I deal with my athlete?" It's okay if I can do these exercises and it's okay if I can improve or increase the load by adding weights and so on.

But let's stop for a while and let's think, "Who is this athlete? What's his real problem?" If it's training load or if it's related to technique, forget about the exercises, then change his shoes. Exercises will help, but focus on what's important if exercises are important, how can I really improve to do something which is better, more individualised, but keeping the same principle for everyone?

So that's why it's impossible to say eight repetitions is better than 12 or worse than four. But I still think that looking at the quality of the exercises is giving you the key. It's stupid to tell someone to do 12 repetitions if after the seventh one he totally lost the motor control, because otherwise you are probably doing something that you didn't want to do.

Or the same, it's stupid to tell someone to do 12 repetitions if he could do 50. Then, he's doing absolutely nothing. So, I think soon, we'll try to publish this in a paper, let's say, the whole concept of how to quantify the load in the exercise, from a qualitative point of view, which is let's say putting numbers to all this reasoning and I think at least that helped me a lot with reasoning why you choose some exercises and not some others and why today you did eight repetitions and not 12. Because it will be a way of estimating the magnitude of the load that goes to the tendon and at the end, I think this is what most of the people need. Reading papers is very nice, watching Netflix is very nice also. But it's science fiction at the end.

We need something that is practical. Practical will be applied by anyone depending on his context or her context and how they deal with that, the type of athletes you have and the type of person you are. As I said at the very beginning, not every one of us has the same profile. Not everyone is very good at communicating concepts to people, but they can use other qualities of being good at prescribing exercises, of diagnosing things or being specific to how to deal with the program.

So, this is why I think we don't need protocols, we need concepts and we need clinical reasoning.

David: Thanks very much for coming on and sharing all that with us. It's been fantastic and tell people, where can they find yourself on social media or anywhere else?

Daniel: I hope people enjoyed this, I hope I haven't been too boring for one and a half hours. Even my wife doesn't listen to me for one and a half hours, so thank you for being there such a long time and I will take the opportunity to tell everyone that all around the world we have nice physios. The more I travel, the more I find people in any country doing amazing things but not publishing them. Here in Doha, in Aspetar, we have really, really incredible people working, publishing, doing really nice things.

But back in Spain, I know some people that is doing amazing work. Unluckily, we are not very good at speaking English, so our work cannot be communicated to the world. But it's interesting that, going, traveling and meeting new people I traveled in Australia like 11 years ago meeting different people and knowing new ways of working and I really encourage people to do that and if you cannot do that, which is not easy, nowadays we have these podcasts, we have webinars, we have all these things that can make us feel closer to clinicians around the world working in amazing ways, because we can almost talk to them directly so, take that opportunity and keep listening to this. I listened to this podcast a lot of times. So, thank you for inviting me and to be part of this is really a privilege.

David: Well, I appreciate you coming on and where can people find you, are you on Twitter or whereabouts are you?

Daniel: Yes. I'm not incredibly active in social media, I prefer to work. But you can still find me on Twitter. I post a lot of things related to physiotherapy and tendinopathy, my Twitter handle is @PhysioDMSilvan, there you can find me. I'll be happy to reply or to interact with people.

David: Really appreciate it, and we've managed to explore quite a lot of areas and I hope people have got lots of good ideas about how they can approach their next tendinopathy patient. So, thanks very much, Daniel.

Daniel: Thank you very much.