Chapters Transcript Video Shockwave, PRP, Tenex or Surgery? Choosing the Right Treatment for Tendinopathy Today we're discussing novel treatments for tendonitis or more accurately in many chronic cases tendinopathy. It's a condition physicians see across specialties Achilles pain, rotator cuff symptoms, tennis elbow, patellar tendinopathy, plantar fasciitis, and gluteal tendinopathy, among many others. For years treatment often centered around rest, anti-inflammatory medication therapy, injections, and in some cases surgery, but the field has evolved. We now have a better understanding of tendon biology, load management, imaging, patient selection, and minimally invasive treatments that may help bridge the gap between physical therapy and the operating room. Together we'll discuss how to evaluate tendinopathy when conservative care is enough, when to escalate treatment, and where options such as focused, extracorporeal, shock wave therapy, 10x, platelet rich plasma, and surgery fit into the treatment ladder. Welcome to Baptist Health Doctor Doc, a podcast built for innovation and collaboration by physicians for physicians. Hello, I'm Doctor Ronald Tolchin, and I'll be hosting today's conversation. Joining me are two Baptist health experts who treat these conditions from complementary perspectives Doctor Raul Rosario, a physical medicine and rehabilitation physician with Baptist Health Miami Neuroscience Institute who specializes in non-surgical musculoskeletal care and image guided procedures, and Doctor William Davis. An orthopedic surgeon with Baptist Health Orthopedic Care who brings the surgical perspective on when tendon disease requires operative repair, debridement, or reconstruction. Good morning to both of you. Good morning. OK, let's start with Um, understanding tendinopathy more than tendonitis. So let's start with terminology. Patients often say they have tendonitis, but in many chronic cases, tendinopathy is more accurately. The terminology. Dr. Rosario Concepcion, what exactly is tendinopathy and why does that distinction matter clinically? Uh, that's very important. I think that's the kind of the basics of how do we treat the tendinopathy problem. We need to understand what's going on with the tendon and back in the day, like you said, we call it tendinitis because we felt that there was an inflammatory response into the tendon. Which there might be a little bit, but it's not the main problem. histopathological kind of testing started like looking into the fibers of the tendon and found that actually there was not a lot of inflammatory cells or factors in there, and it's more of a degenerative problem. So the collagen is not a strong collagen type 1, it's more of a type 3 collagen problem. Uh, and that kind of shifted a little bit the way that we treated this problem, and it's important to distinguish that because that's why it's a chronic issue of a degeneration of the, of the tendon. And it's not like an acute problem, it kind of uh convert into a more chronic problem and we need to kind of treat it. So now the term that we use is more tendinosis, more like a radiological imaging kind of term, tendinopathy, it kind of encompass kind of a big, a broader kind of a problem to try to kind of treat this issue. Very good, thank you. So, Doctor Davis, from an orthopedic perspective, how do you think about tendinopathy structurally? Uh, very much the same way. It's, it's, um, it is, um, much less of a tendonitis condition and more of an actual mechanical problem with the tendon. Um, and we, we will see this in, in patients and, and they notice in their daily lives, they'll notice even weakness, but a lot of it is pain and distinguishing between a tendonitis and, uh, a tendinopathy is important. And that's where the physical exam and our, uh, and our imaging modalities come in to, to play with that because it really does guide treatment. OK, well, Doctor, um, Rosario Concepcion, when a patient comes with suspected tendinopathy, what's the first thing you're trying to determine, and what does first line treatment usually look like? Yeah, number one, it's important I again with everything, have the right diagnosis, so the history, the, uh, and the examination becomes the key of trying to diagnose this problem. Usually this is a clinical problem. Uh, so with the history and the exam, you can diagnose tendinopathy. So we want to kind of evaluate different things. Number one, where is the pain, uh, how long has been the pain going on, and usually I like asking if there's a new activity because this tends to be like an overload problem. Most of the time we can identify that the patients started playing tennis a couple of months ago. Probably their technique and biomechanics is not the, the greatest. I don't know about that, but. But definitely that's something that we need to explore because uh if we don't tackle the root of the problem, then the treatment becomes more difficult. So if their technique in tennis, for example, they're using their wrists too much instead of their body, then they're overloading the tennis elbow that we, that we discussed. And if we don't address that, if we treat it, it's going to keep coming back because we didn't address the roots. So at the end of the day, we have to. Have a correct diagnosis, we have to identify the risk factors. We have intrinsic and shrinking risk factor, but at the end of the day, sometimes the equipment that they're using, the, the, the racket, the tension in the, in the string is too, too tight and it's putting too much pressure in the elbow. So those are things that we need to identify to create that kind of first step in treatment. And talking about that, I, I feel that 3 things are important when we're starting to talk about tendinopathy to the patient. I feel that we don't do enough of education to the patient, which I think is key in the treatment. Every patient wants like an easy fix. I have pain in the tendon and, and tomorrow I want to keep playing tennis, and they need to understand that there's no quick fix with tendinopathy. We need to kind of, uh, work on it, and it's going to take us like probably 36 months to kind of get you back, because of the chronicity of the issue. So we have to educate the patient on why this is happening, why it's going to take this much time, so they kind of think about it and put the effort in the treatment. Number 2, identifying why this happened, which usually is like a, a, a problem, a new activity, or, or, or a new uh exercise that they're doing. And the third is then uh strengthening, right? And, and that's where physical therapy kind of comes into play to try to help kind of guide the patient in what they need to be doing. But at the end of the day, we have to do like a progressive loading of the tendon. One of the issues that that it happened is that the tendon was not ready for that level of activity, so we have to kind of make the tendon a little bit more prepared. So we have to slowly start loading the tendon and the therapy can guide us with that. So it's not just physical therapy, the patient has to kind of start loading and progressing, and that's kind of the best initial treatment that we need to do. An important point that I always tell patients is that strengthening is not easy, and, and you cannot go to the gym and one week later be strong, right? It's going to take us a couple of months to start seeing the difference, to allow the body to put these kind of weak fibers and stronger fibers in there to kind of fix the issue. So what do you think then is a reasonable conservative timeframe for patients like that? So usually I, I like doing at least 6 to 12 weeks of conservative options. Uh, it takes a long time to kind of change the structure of the tendon, uh, put new fibers, stronger fibers in that area. So, that's one of the things that we have to educate the patient that we have to be patient with this process. Uh, in order to kind of, um, get better before we start adding maybe other things that can be adjuvant in the treatment, and it never changed the basic of the treatment, which is the strengthening component. So, to follow up beyond that, Doctor Davis, um, when do you become concerned that a patient may need an earlier escalation towards a surgical, um, procedure? Well, I think the imaging that we get MRI typically, um, in, in a sports medicine office would be the, the main way that a surgeon is gonna be diagnosing, um, uh, tendinopathy on imaging can, can give us some indication of whether this is, you know, mild or severe or somewhere in between. Um, but it still doesn't change the fact that for, for most of the time, we, we are gonna start with the conservative measures as Raul was just talking about it. It really, you know, physical therapy is the, is the mainstay, um, cause You know, the, the, the old saying, orthopedics say, we don't treat the image or we don't treat the X-ray, we treat the patient. And, you know, somebody may have bilateral shoulder MRI's, for example, and, and the one that looks worse may not be quite as symptomatic. And so then there's a lot of things that go into that, mechanics, um, hand dominance, um, activities, what they like to do. Um, all those things play into it. So I do think it is, it is very important to, to, as you said, to educate the patient early on, kind of set the, the time frame for expectations, um, and really get the patient to buy into doing the therapy because a lot of times it does work and the MRI may not change in appearance if you were to get one later, but their symptoms do. And, and if, and if that allows them to do the things they wanna do and not be at risk for, you know, more catastrophic injury, then that's a, that's a win. Perfect, perfect. So let's move into the treatment ladder. Doctor Rosario Concepcion, one of the newer options getting attention is focused extracorporeal shock wave therapy or FESWT. What is it? How does it work? And who's the ideal candidate for that? Yeah, that, that's a, a newer technology here in the United States. It has been used in Europe for many decades, but it has become very popular in the last 5 to 10 years in the sports medicine field, PMLR fields, orthopedics field. And basically what it's trying to do is create this kind of mechanical acoustic signal into the tissue. So that mechanical acoustic signal gets into the tendon and creates this kind of biochemical signal, and the idea is to try to wake up that healing response of the tissue of the cells or or of the tendon fibers, so I kind of go through this kind of healing process. Going, going back to what is tendinopathy, the problem is that the tendon got injured and it kind of stopped the healing process and it became like a chronic issue. It's a kind of a failed healing process and that's why it's so chronic. So the idea of the focused extracorporeal shock wave therapy is kind of create this kind of disruption in the biochemical structure of the tissue so we can wake up that kind of healing process again, and we always like combining that with the strengthening program. We never forget that part because then, You can start putting like weaker fibers and then stronger fibers and then hopefully that kind of improve the integrity of the tissue. What kind of results are you seeing with that? We're seeing great results and sometimes I'm even surprised with the results. Definitely a study says that it doesn't work on everybody and we have to kind of make sure that. Patients that are a good candidate for it, but studies have described like most, almost like 80, 85% of patients can respond if we have the right diagnosis, right strengthening program, and, and we incorporate some focused extracorporeal shock wave therapy. So we're having great results, especially for plantar fasciitis or fasciopathy. Uh, tennis elbow, uh, Akila standing up, but especially mid portion tend to respond very well, and, and there's different type of, of focus shock wave, um, but the one that we have in the electromagnetic, there's also electrohydraulic and piezoelectric type of focused shock wave, but at the end of the day, what it does is sensitive mechanical acoustics. Uh, signal and it kind of focus it into the tissue. I kind of, it's like a, if you have like a magnifying glass and you put it in the light, I kind of focus the light in one spot. So that's what the focus shock wave is doing. Now, I think it's important also to distinguish from the radial pressure wave, which is a common um uh another device, right, that can be helpful in some patients. Some people call it shock wave, but the correct term should be pressure wave because it kind of works differently. It's more of a ballistic kind of pressure, and the pressure and the energy stays very superficial into the skin, so it doesn't focus into the tissue. Now there's, there's a big role that can be also helpful in a lot of patients, especially with superficial tendinopathy like tennis elbow, like epicondylitis, tennis elbow, common extensor tendinopathy. Uh, that can be helpful and sometimes some, some physicians use both as, as an adjuvant to try to treat this issue. So then where does this other new, uh, procedure, 10x fit into the ladder of treatment? So that's a little bit more later on the spectrum because uh at the uh we're kind of now disrupting a little bit that tissue. So we're trying to kind of create the same irritation into. The tissue to kind of jumpstart that healing process, but with this procedure, there's a small incision. We introduced this device that use oscillation and vibration, we call it ultrasonic tenotomy in that area. And the idea is that it goes into the weaker section of the tendon and we use ultrasound guidance to make sure that we put it in that area. And that area has the collagen tree that we were mentioning that is weaker, so that oscillation cannot disrupt those fibers. It shoots saline and reabsorb that saline through the device to try to clean out that area. So the idea of something like that is doing like a mini surgery or a mini tenotomy in that area to create this disruption of that area, so the body sends cells, healing factors, and kind of call everything that you need to heal that tissue. Since it's a little more invasive, there's some protection that we have to do, some restriction in lifting for a couple of weeks, and there's a rehab after that, that like any kind of mini procedure or surgery that we need to do. So there's a longer recovery period, but we're seeing good results with some kind of tendon. Apathies that the patients have not responded after 3 months or more of conservative treatment like the shock wave or the physical therapy and you're doing that more in a procedure location, right? We have a procedure location we use ultrasound guidance. We do ductal numbing so there's no general anesthesia. Patients go to their home the same day. There might be a flare of pain for a couple of days after, uh, but it kind of decrease very quickly because we're not like doing a big incision or taking the tendon out or anything like that. So, so the response has been great, uh, uh, again, if you select the right patients that uh is uh. Might improve with this uh procedure and they tend to do very well. Uh, in, in comparison, the shock wave doesn't require any anesthesia, any downtime, so that's the benefit of, of that is that we don't have to stop necessarily your level of exercise or activity. So we like doing it for athletes that are in the middle of the season, for example, that if we do something like a PRP or 10X, we have to take you out and maybe we prefer to do that in, in the offseason. In the season, extracorporeal shock wave therapy can be a good option that they don't have to kind of stop their activity and or the strengthening. Correct. So what about platelet-rich plasma or PRP? It's another option that gets a lot of attention these days. Is it overhyped? Is it underutilized? Is it somewhere in between? Um, what do you think about that? The way that I visualize it is that there's, it's another tool in our toolbox, right? As you see, there's a bunch of tools that we can use, so that means that there's not a single one that works on everybody. And sometimes we have to complement each other. So, uh, there's a lot of evidence for tendinopathy, especially for tennis elbow, glutus tendinopathy, plantar fasciopathy, uh, that PRP and plaque-rich plasma can help. Basically it's the same idea. We're trying to create this disruption into the tendon, but in this case we're taking your blood, we're spinning around, trying to concentrate the platelets and the healing factors in your blood. Created disruption with this needling, but also, uh, put the healing factors in that area to kind of promote that. Now, that hurts a lot, uh, a lot, uh, there's some recovery time, there's some rehab after and we don't see that benefit until like a 3 months, so there's still like a, a rehab process, and we never start with that option in my opinion. We kind of try the conservative approach and then we can incorporate that as another tool in our toolbox, but definitely it's something to consider and, and there's a lot of studies that it can uh support it. And some of these newer treatments, they really are not covered by insurances yet, right? So patients are paying out of pocket for some of these things, correct? Correct. Yeah, well, what about steroids? We've had, that's been the mainstay of treatment. Everyone knows about steroids, not everyone knows about some of these newer things. Where do steroids fit in? So, so this, this is my thought with steroids. I, I, I, I think there's still a big role for the use of steroids, but we have to be more careful on the use of steroids, I think. Back in the day, we abused the use of steroid and, and everybody with this pain, we thought it was inflammatory and we put steroid in there, and what happened is that it worked for a couple of months and then it came back because we didn't treat the root of the problem, and then what happened is that we start learning that the steroid maybe start weakening even more the tendon now. For tendinopathies that also, there's a bursa on the top like rotator cuff and gluteus tendinopathy, that's the trochanteric bursa and stuff. I think there's still a role of, of the steroid in the sense that if there's a way that maybe we can control the pain. Decrease the pain so they can do the therapy and the rehab and start loading the tendon a little bit better. I think that makes sense to kind of do a little bit of one steroid injection. Now, what we have to be careful is that we don't want to every 3 months start injecting steroids because then we get into trouble. We're probably doing more. Harm to the tendon that any good and that's where these other plays start coming into play. Uh, there's some tendons that maybe we should not do it. There's some evidence that maybe for tennis elbow we should stop doing it for plantar plantar fasciopathy, we stopped doing it because the results in the long term has been bad in research. Uh, but I still think that in special cases, uh, there's still a role. I don't know. What do you think? No, I agree completely. I mean, it, it, like you said, it all comes down to the diagnosis and, and if you're putting cortisone into a tendon that has tendinopathy, that's not going to treat the underlying problem. But like you said, if it allows them to do the physical therapy more effectively because you control some of the, the overlying bursitis that. That is a reasonable thing to do. And a lot of patients do need that little, that little bump. Now, we also also use other things like non-steroidal anti-inflammatories and things like that to accomplish that same thing. Um, but you know, steroid is, it's not evil. It has its role and, and, and can be used effectively if done so judiciously. But it can also rupture. Too, it could rupture tendons, correct? Absolutely, yeah, yeah, that's one of the risks, especially with weight, weight bearing tendons like the Achilles tendon. We don't, we never do it, we never do it and I'm extra, extra, extra careful in the posterior tibialis, anterior tibialis. So, uh, definitely yes, in weight bearing tendons you have to be more careful, um, but in. Upper extremity probably you can be a little more flexible. Perfect, thank you. Let's talk about imaging for a minute. It could be incredibly helpful, but it can also lead us astray if we overinterpret it. What do you rely on the most, ultrasound or MRI and how much do these findings drive your decision compared with the clinical picture? I'll go first. Sure. Yeah. So, as a, as a surgeon, I'm much more accustomed to looking at MRI. That's what we use in, in our, our surgical planning for a lot of these conditions. So for me, I do, I do tend to personally rely on MRI. Um, however, ultrasound has its role and, and I will send people to Raul and some of our other, um, some of our primary care sports medicine doctors who are very good with ultrasound and we can get a lot of information out of these things. There's also Um, which you could speak to probably better than I can, the ability to assess a dynamic view of a tendon or ligament. I'm talking about tendinopathy here, but with ultrasound that you can't really do with the MRI, right? You do that a lot, right? You do mostly everything with ultrasound. Yeah, I believe it's very complimentary, right? Um, but MRI has been the traditional kind of gold standard because you can evaluate the joint, for example, and help with the differential diagnosis to make sure nothing else is going on there, but also you can see the tendon. But with ultrasound, I think the image quality that now we have with this ultrasound machine is superior. Now, is, is uh user dependent, so you have to know what you. Looking for and, and I have been training it, but if you are very good at it and, and, and know how to get a good image, you can get even more information sometimes with the MRI, especially with the dynamic motions that you can assess like ligament tears or, or, or bigger kind of snapping sensation that the patient might have, and you can figure out what's going on. At the end of the day, complementary, I think both has a big role, and if the clinical presentation is very classic, I think ultrasound definitely, um, it would be enough and superior in some cases. If there's some doubts, maybe the MRI can give you more information around the joint that maybe the ultrasound is limited because it cannot penetrate inside and see cartilage damage and things like that, that, um. MRI might be superior. So, but both I think are extremely important if the clinical presentation or the patient is not improving as expected because maybe you don't need the MRI from the beginning or an ultrasound from the beginning, uh, but if the patient is not getting better, then you start getting more imaging to kind of confirm the problem. Or even after surgery in some cases, right, when it's a diagnostic dilemma and the patient's not recovering as expected, right? Exactly, exactly, it can give you additional information of, of how to kind of take the next step to the patient. OK, so Doctor Davis, let's turn. Surgery. When is surgery the right call for Achilles tendinopathy, and how does that differ between the mid portion and the insertional aspect of the disease? Yeah, with Achilles specifically, we're still starting with the conservative measures first, obviously. We're doing the physical therapy um and um you know various other lifestyle changes that patients can do to help with those things. But Um, when the decision to, to go to, to surgery is often with the patient and specifically with, with Achilles, the, the, the thing that differentiates it from, you know, uh, lateral epicondylitis, for example, is the recovery from any surgery. With a lateral epicondylitis, a debridement and repair, several weeks to several months of doing, you know, doing a little bit of physical therapy, but it's not that life-altering. Whereas if you take someone's, you know, right foot and, and you're doing an Achilles debridement, you're detaching it, excising maybe 50, 60% of the thickness of the tendon, repairing that down to bone, possibly doing a tendon transfer, an FHL transfer along with it. This is a, a big surgery for one, more, more risk involved in that, and two, the recovery really is a good bit longer and more life-altering. So a lot of times we will, you know, um, uh, do kind of extend the non-operative treatment a little longer than, than you might otherwise suggest. And, and in addition, just because of that, you know, we talk about players in, in season and things. Well, people have seasons of their lives. To, you know, they have a ski season coming up or whatever it is that they, that they wanna do. So we will often, um, with when you have that much of an impact to your life with the surgery like, like an Achilles, uh, debris minimum repair, um, those things have to be taken into account. Um, having said that, it, you know, it, it is a good option for patients when they do reach that level, and we can, we can help them a lot. What percent of patients would you say would go to surgery for lateral epicondylitis? Oh, more with, with the advances in, and, and a lot of the non-operative things, it's a, it's a very small percentage. I would, I'd, uh, I'd be, um, I'd be guessing if I gave you a number you might actually, no, I think it's low. I think it's low definitely but probably it's higher in the Achilles, would you say, uh. It depends. I think, you know, a lot of it too, it may be changing with, with some of the, you know, the advent of pickleball if you will, it's, uh, people are being active in the, in the later years, um, and people that probably otherwise would have just shut it down from, from sports and exercise activity, um, wanna remain active and so we are, we're probably, um, seeing an increase in, in, um, and just more invasive interventions whether it's, um, some of the procedures that you're doing or surgery. Let's talk about something that's near and dear to my heart. I've had two rotator cuff surgeries already. When does rotator cuff tendinopathy cross the line into something that needs to be fixed surgically? That's, that's a great question. So a lot of times it comes down to whether or not someone's sleeping, and they can't sleep at night, and they've, and they've tried the non-operative measures. At that point, people will, you know, they will often elect to have, uh, a rotator, an arthroscopy and potential debridement versus possible repair. Yeah, I think rotator cuff is more tricky than other tendons because rotator cuffs are actually 4 tendons, right? So you can have a tear in multiple tendons, you can have a partial tear, articular sided, bursal sided, interstitial tears. So it's kind of a little bit more of a comprehensive kind of problem of tendinopathy. I know when there's a full thickness tear, I know, and it like I've kind of reattached the tendon with PRP or or shock wave, so that's probably where surgery comes a little faster to try to kind of take a look into it. But if it. Like a smaller tear or articular site interstitial tear, probably patients tend to respond a little better with a conservative approach. So I always try to kind of do a diagnostic ultrasound when patients are complaining of rotator cuff because if I already find from the beginning a full thickness tear, then I send already to the surgical experts to kind of get their opinion in terms of if this is something that we. To be a little more aggressive faster depending on their clinical presentation, their sleep, and all those things, uh, and their age, their level of activity, of course, uh, correct, multiple decisions, but we have to get them involved. Now if there's a small tear or no, there's no tear at all, then maybe we can start with kind of all these options that we have discussed today. And if they're not responding then we can always kind of uh get them involved. Why is nighttime so crucial? Uh, we have to sleep, of course, but why is the pain worse at night, do you think? Because you're turning on your side and you're laying on it, that's a great question. Sometimes it's because you're turning on your side, laying on it. Other times it's positional, even postoperatively. Some patients, you know, we have, we, we suggest they sleep at a 45 degree angle or in a recliner chair, things like that. That's a lot of fun, isn't it? Yeah, oh yeah. And so, um, and so, and then some of it is just your, you know, your. You're there in the quiet in the dark and it's right, it's right there next to you and, and it's just something that you're thinking about. Uh, but it is true that it does, it does seem to have a unique way of keeping people awake at night where compared to other injuries, you know. OK, thank you. Let's close with a few practical takeaways, Doctor, um. Um, um, Doctor, uh, Concepcion, um, what are some, uh, the most underutilized non-surgical treatments in tendinopathy? So probably now I will say that the shock wave, right, is newer, it's more popular. Not everybody has it. We just got it recently. So I think what we're seeing is can be like a quick adjuvant to the conservative approach and sometimes we start with therapy and the patient don't get better, then we incorporate the shock wave, but more recently we're having good results and it's so conservative with no side effects. And no persistent pain and no kind of big risk and contraindication that we're kind of starting it early on, and I feel that the patients are responding very well, so I'd probably say that the extracorporeal shock wave therapy is something that maybe in the future we're going to see that is going to be implemented early on in the spectrum of treatment of tendinopathy because the results are actually fantastic. Thank you, Doctor Davis, what about, what is the most overused surgical procedure or surgical mindset in tendinopathies? I'm not sure there's one surgical procedure that's, that's overused, um, necessarily. I, I think the, the, um, The mindset is, is that we have to, with the goal of surgery is to, is to try to get Healthy tendon Uh, down to healthy bone for the most part. I mean, obviously there's mid-substance things and things like that, but whether the concept is, um, you know, mid-substance or insertional for rotator cuff, Achilles, whatever your pathology. You know, you talked about the degeneration of the tendon and all the, all the modalities, whether it's, whether it's the, the physical therapy focusing on eccentric strengthening, whether it's the PRP injections or uh the 10X or surgery, we're trying to get rid of the diseased tendon that has burned out, has stopped its healing process, and, and repaired that back down and get it. And one of the best ways to do that surgically is to Physically to breed it out and then, um, repair it down to healthy bleeding bone surface. And it doesn't stop there, obviously, because there was the underlying problem that allowed it to begin with. So, physical therapy, not just to rehab the, the tendon after surgery, um, but to prevent this from coming back in the future once they've rehabbed it, um, is, is, is very important. So I think as far as mindset, that's, that is, you know, what we, what we have to, to think of as, as surgeons, not just Right, not just cut. Yeah, so what emerging treatments are you most excited about in this space? This goes out to both of you. Go ahead. Yeah, the, the emerging right now, um, is, is probably the shock wave and, and the kind of minimally invasive kind of procedures that we're offering, um, so I'm very excited about the outcomes that we're getting and, and the results, uh, we just have to be careful in the right patients and, and the right problem and never forgetting kind of the root of the issue and kind of controlling that also. Um, so I'm just excited about all this new technology that is coming up. Tendinopathy is a tough problem, so anything that comes up, we're looking into it to see how it can be a big role in helping patients getting back to a high level of activity. Which is our goal. I'm a sports medicine doctor, a sports medicine doctor that we always try to get the patient active and get them back to a level of activity. It doesn't matter their level. Uh, it can be a professional athlete, it can be that you like playing peekball now. Uh, so we just have to kind of help the patient get back to where they need to be, uh, they want to be, uh, so anything new that, that comes up, we always take a look and, and, and see how can we apply it, um, uh, to the patient. Excellent. So you, you, you, you're even using PRP. In conjunction with surgery, aren't some of the orthopedic surgeons doing that? Yes, at times, yeah, for that same, that same idea as we're doing everything we can to try to, to try to, to, to reverse the cycle, to get, to get rid of the, the tendon that has stopped, you know, trying to heal, um, and if we can do other things like PRP in conjunction with surgery, it absolutely can help. So final question for both of you, what's the single best piece of advice for a patient who just got diagnosed with tendinopathy and what would you want referring physicians to remember out of this discussion? And, be patient. That would be my, my, my big word that I use with patience is like, hey, we have to, to be patient with this, we have to work hard, we have to kind of take seriously the strengthening portion. That sometimes patient um little lazy in that component of, of, of rehab. So they need to understand why this is important, so I emphasize that. And then all these other tools that we have in our toolbox that we can kind of add as part of an adjuvant of the treatment, never forgetting the root of the treatment plan, which is going to be the loading and progressive loading. And Doctor Davis, how about you? Patience is, is the number one thing, but the other is, is that it's an active process, meaning it's an active. On the patient's part, uh, of, of getting better. Um, the, all the things we do, whether it's surgery or the non-operative interventions, um, they all, they all don't work in isolation, and the patient has to understand that, that it really does take their, their, um, willingness to buy into the, to the, to the either. The non-operative therapy or the the post-treatment therapy for this to be fixed. And my take is it takes a team, right? It takes a team effort of excellent, well-skilled clinicians that can work together and really work in the benefit of the patient for the patient. That's absolutely right. I mean, we, we send people back and forth, so it's not an either or thing really. It's, it's, it's like you said, tools in a toolbox and we use these things in conjunction and um. You know, if, if we can do as much as we can to, to, to keep somebody from having to undergo surgery and they have a successful outcome, that's great. And then if they fail those things, well, then the patient and the surgeon and the therapist can be more um confident that, that we've reached the point where surgery is the option and, and, and we can do that and, and go all in. Thank you both. For our physician listeners, the takeaway is clear. Tendinopathy care is no longer a one size fits all pathway. At Baptist Health, multidisciplinary collaboration allows us to offer patients a full spectrum of evidence-informed treatment options from rehabilitation and non-invasive therapies to minimally invasive procedures and advanced surgical care. For more information about the topics covered on Doc to Doc podcast, please visit physicianresources.baptisthealth.net. Thank you Doctor Davis and Doctor Rosario Concepcion for sharing your expertise and for the work you're doing to advance musculoskeletal care at Baptist Health. To find out more about the topics covered on BaptistHealth.toc, please visit physicianresources.baptisthealth.net. Created by
