Orthobiologics Effectiveness for Tendinopathy Treatment

: On today's episode, OrthoBiologics effectiveness for tendinopathy treatment. Welcome to the podcast helping you overcome your proximal hamstring tendinopathy. This podcast is designed to help you understand this condition, learn the most effective evidence-based treatments and... bust the widespread misconceptions. My name is Brody Sharp. I'm an online physiotherapist, recreational athlete, creator of the Run Smarter series and a chronic proximal hamstring tendinopathy battler. Whether you are an athlete or not, this podcast will educate and empower you in taking the right steps to overcome this horrible condition. So let's give you the right knowledge along with practical takeaways in today's lesson. Hello, PHT rehabbers. This is a repurposed episode. I recorded this for the Run Smarter podcast a couple of months ago, and we're talking about orthobiologics, which essentially is elements of treatment like PRP, stem cell therapy, other injectables, those sorts of things. I walk you through a few papers. So we cover three papers in particular. And they are. I guess I'll go through the titles now. Orthobiologics, diagnosis and treatment for common tendinopathies. Then paper number two, the applications of orthobiologics in Achilles tendinopathy. And then we go through paper number three, the effect of high volume injection, platelet rich plasma and sham treatment in chronic mid portion Achilles tendinopathy. So take it with, I guess a grain of salt because it's not directly PhD related, but you'll come out of this with a lot more understanding about these therapies and their effectiveness. I thought it was very handy and that's why I decided to cross this over from the Run Smarter podcast into this main feed. So hope you enjoy. Firstly thanks for the kind words and well wishes for my partner and I expecting. I announced that sort of last episode. 1 million download milestone, got a lot of lovely feedback and lovely responses. And it's always good to know that it's more of a community and that, you know, alongside the congrats, this podcast is great. It's helped me with blah, blah. That it's really good to hear. Very good to read. Makes my day reading those sorts of things. So thank you. Um, we're going to dive right into this particular content. Um, thanks to Laura, who is a patron. And. while I was asking for questions for the past Q&A's that we just did, Laura posted and said, are you up to speed with the newish area of orthobiologics, PRP and stem cell injections primarily for tendinopathies? She then linked a study and said this might be interesting as a whole podcast episode down the road. So yeah, thank you, Laura. I'm doing that now. And I must admit the term orthobiologics, I had no idea, but obviously PRP and stem cell injections I was familiar with and read most of the papers along with a few others and thought I would, yeah, I thought it would be an interesting topic. So here we go. Let's start off with, I guess the term. So orthobiologics, what is it? So it's a term that describes biological agents like biological material applied to a musculoskeletal injury. And so that biological material is usually, um, from the body or from your body, hopefully, and then injected back into you to help with an injury. Um, the most frequent form is, um, ultrasound guided injection. So people are familiar with like an ultrasound. So they kind of use the combination. They can put the ultrasound on the area that they want to inject. Then they insert the needle and that can actually see where that needle is going. Can see what tissue it goes into and then inject it. So it's a lot more accurate. And it's used to reduce pain and to facilitate healing. Such agents include platelet rich plasma or PRP and stem cells. These substances are used to treat a variety of musculoskeletal problems, I'm just reading what the paper says, such as tendinopathies and osteoarthritis, acute muscle injuries, and their use is becoming increasingly relevant for young and older age groups. The initial theoretical foundation for the use of these orthobiologics derived from the recognition of limited regenerative capabilities of the musculoskeletal system. So they're saying that you know certain cartilage or certain tendons or certain ligaments They don't regenerate or heal. They have limited capabilities. I guess is what they're saying So it was hypothesized that the injection of growth factors Typically derived from the patient's own blood would enhance this regeneration and repair. So taking some blood or something out of the body, sort of breaking it up and I think they spin it or something and so they collect when blood is span. It can be split into different groups and different types of forms and so one of that forms is platelet-rich plasma which has a bunch of healing growth factors and if you take that and then inject it into something that has poor healing abilities. hopefully it stimulates that healing. So that's all in theory and that's what the, the paper is talking about. Um, I had some ideas prior to reading this paper. I've looked at a little bit of PRP, mainly what the gurus that I follow, what they've talked about when it comes to PRP and injectables and that sort of thing. So I thought I'd share that first, sort of what my ideas were coming into reading these papers, just so you get a better understanding. Firstly, like the researches that I follow, which would have been five years ago, I think this statement was made. And, you know, probably a lot of research has come out since then, but research is saying, just don't inject anything into tendons, just don't do it. Like there's no need for it. The risks of changing the cellular structure or the risk of some complications down the track, doesn't outweigh sort of the benefits of just doing some exercise. So there's probably no point in doing it. So that was my, I sort of prescribed to that sort of idea and that thinking. And then second, after that, I had Peter Maliaris on the podcast. In the early days of the podcast, I think it was within the first 30, 20 or 30 episodes. And he said that all injectables, I think he used shockwave in there as well, shockwave, PRP, corticosteroids, he was saying that research has shown it's not more effective compared to placebo. So there are some studies out there that mention PRP is beneficial overall when compared to say something like a corticosteroid. So they're taking two treatments and comparing the two and then saying, oh, PRP is more favorable. And so that paper can lead you to think that, oh yeah, PRP is the, the way to go, but he cautions on that podcast saying, um, but it's only because the corticosteroid can be harmful in the longterm. And so in the short to medium term, they seem to be about the same longterm steroid is harmful and so PRP comes out on top and so they're not comparing to. a placebo, they're not comparing to a control, they're not comparing to exercise alone. But yeah, so we do need to be careful with how we interpret these particular studies. And he did mention that the only one real bit of evidence is exercise therapy. And then he sort of backpedaled a little bit and he says, well, pretty much exercise therapy, he sort of didn't say that was too conclusive. He was being very impartial and just very much sticking to what the research shows. but he said that if anything, it was exercise. So strengthening, raising the capacity of the tendons, which is sort of my philosophy as well. But then, okay, so I've had these two encounters to sort of gather my own sort of ideas about PRP and injectables and that sort of stuff into tendons. And then three, what I have seen with the clients that I work with. So for those of you... unfamiliar, I also have a second podcast, the overcoming proximal hamstring tendinopathy podcast. And that generates a lot of my clients. I there's 80 odd episodes, they're all about how to prevent, overcome, treat, understand proximal hamstring tendinopathy. And currently, for the last two years, 80% 70 to 80% of my entire caseload is treating PhD. And so I've seen a lot. Um, and usually by the time they've got to me or by the time they found the podcast and then decide to do, um, make the decision to have a chat with me. They've usually been through the ringer and seen a lot. They've done exercise therapy. They've done PRPs. Some of them have had surgery. They've had it for several years. And so I'm getting this group of people that have tried everything. So I'm sort of getting the worst of the worst in some circumstances. So my, um, the population I'm seeing is just a little bit skewed. I might be a little bit biased based on this skewed population because someone could just as rightly had PhD, had PRP being completely fine and then not seen me. So, um, you know, I might have a skewed balance, but I've seen some horrible outcomes with PRP injections. Um, the, uh, I guess some people, If I were to get 10 people who have had a PRP and then seen their outcomes, I think about 60 or 70%. Oh, I'd say 50% actually feel worse. I'd say about 40% feel indifferent after a couple of weeks. And I'd say maybe 10 to 15. I could probably just thinking right now, think about two or three that have said, yeah, PRP worked for me. And so. that's, they're pretty, pretty bad odds. But then I also, with the clients and I guess my understanding of this, with the clients that I work with, no matter how bad they are, how long they've had it for, how severe, we just do a loading program. We just do load management and they get better. And so this is all like sort of confirming for me, based on what researchers have said, Peter Maliaris, I should say, he's like one of the world's best. tendon researchers. So we're looking at the top tier here. All of this is sort of just forming my own ideas about these particular treatments. And yeah, it's a thought I just sort of lay out this. So I'm also a bit, I guess, primed based on my previous experiences and understanding of this when reading these papers, which are more recent, we've got a 22 paper here that we're going to discuss. Um, and so I want to remain unbiased. I want to remain or try and be as impartial as I can. I try my best. Um, hence sort of making this episode. I tend to not like when a podcast or a blog or someone or research that I follow like tends to have a bias or tends to Like I find myself wanting to be unbiased. I'm like, okay, this is the people's podcast. This is not just about me. This is like getting evidence-based information out there. And I don't want any of my preconceived ideas or judgments and things to bias that, but it's really, really hard. It's really hard if you feel poor about something, um, to do an episode about it at all and have an impartial view about it. And so as soon as. Laura, as soon as she mentioned that, okay, how about you do an episode on PRP? My initial instinct was like, no, I hate PRP. Just because I've seen how poor it can be with some clients. But like I said, I might have a skewed population size sample size coming to me. And so that has maybe skewed unnecessarily. And so, yep, tried to put that aside, tried to be unbiased, tried to be impartial and out with these papers. So Laura sent me two recent papers and like I'll say throughout this I ventured into a few others. The first one was called Orthobiologics Diagnosis and Treatment of Common Tendinopathies. So it's just looking at overall what the treatment is like. I said it was in 2021. Scrolling down there was a heading that said Tendinopathies Commonly Treated with PRP. And then they had subheadings and they were going through all these different, um, tendinopathies commonly used while the PRP is commonly used to treat. Um, the first one was rotator cuff tendinopathy, which is in your shoulder. I skipped that straight away. Um, the second one was lateral epicondylitis, which is tennis elbow. I skimmed through that. Um, then we got to patellar tendinopathy, which is the tendon at the front of your knee. Um, Not that common in runners, but we're looking at the lower limb now. We're looking at something that might appear in runners. So decided to read that. And so within this particular section, they mentioned that studies regarding the use of PRP in the treatment of patellar tendinopathy have also yielded mixed results. So they're gathering all this data and saying, okay, we're a bit, we're a bit unsure with coming up with some conclusions. Comparative studies investigated. So these are the studies that they sort of pulled together for this review. PRP versus dry needling and exercise. They had 23 patients in total. PRP plus PT versus shockwave plus PT. So they all got exercise or strengthening, but one used shockwave, one used PRP. That was a total of 46 patients. PRP versus PT alone, which is more interesting for me, but there was only 15 patients in that population size or that sample size. So already we're looking at not the greatest sort of combination because we don't have a lot of controls. We don't have like a placebo or a bias or a control group, and the sample sizes are pretty low, but nonetheless. the paper continues and says, compared with dry needling, PRP patients had greater improvements in pain at 12 weeks, but the pain returned at six months. So again, this isn't comparing to placebo or comparing to exercise therapy, but saying that PRP seems to have greater improvements in pain at the 12 week mark compared to dry needling. In comparison with shockwave therapy, provided greater improvements in pain at 2, 6 and 12 months. PRP versus PT alone showed no significant difference in pain scores. So that's probably the comparison that I'm more interested in because I would go down the PT route and sort of load them up, give them some exercises and seems that PRP had no significant difference, which yeah, it's hard to say. there was 15 patients in that study, so maybe there is a difference and just not shown because there's not enough people. But that's what they said about patellar tendinopathy, we're still, again, mixed results, scratching our heads. The next subheading was around Achilles tendinopathy. And they go on to say that, although smaller studies have pointed towards improved functionality, even up to four years after the procedure, RCTs and meta-analyses have been less conclusive. So again, some smaller studies, some smaller studies have shown that it's quite beneficial. PRP would be beneficial for Achilles tendonopathy, but then you look at something that's a bit more robust, like a randomized control trial or a meta analysis, which sort of gathers multiple RCTs. So we're looking at like top tier sort of designs. They're still scratching their heads. They're still coming up with mixed results. A recent comprehensive systematic review in 2019 with a network of meta-analyses of, they used 29 RCTs, so they gather all these randomized control trials, put them together and see what the conclusions are. They evaluated multiple therapies including a weight and C group, a placebo injection, I think they used saline for placebo injections. They used high volume injections. prolo therapy, PRP injections, shockwave, acupuncture, night splinting and multiple combinations of these. So, you know, looking at a very comprehensive systematic review of all these things. And the paper says that all the included studies were at moderate or high risk of bias. So looking at these sorts of things. In a paper, you wanna make sure that there's no or. minimal bias as much as possible. You want to make sure that people who are conducting the studies, the people who are reviewing the research and the results, want to make sure they don't have any bias, a bias. We want to make sure that the subjects themselves are sort of none the wiser of what's being studied so that they don't report like less pain or more pain based on their influence. So even though they had moderate and high risk of bias, all these particular studies they found one new follow-up showed that injection therapy, exercise alone, exercise and injections and exercise and night splinting all were comparable in terms of symptom reduction. So we're looking at all of them sort of getting better at the same time or at the same rate or something. And keep in mind this is like exercise alone is one of those subjects in their exercise and injections are a component in their and injection therapy alone is in there as well. And they all seem to show symptom reduction. The paper doesn't say like how much, how good it is, and what sort of time scale. But that's what they said. The authors ultimately concluded that the studies elevated risk of bias creates uncertainties with choosing a specific treatment. So you're going to get used to this if anyone's ever a researcher out there and um, do a research on a particular topic and they find these big studies. It's sort of like the bigger the study that gets or the bigger systematic review there is, it's seems to always be at the end, um, you know, we're still unsure or there are more studies that are needed or better quality studies that are needed. It's very disappointing, but this seems to be the case for this particular paper. So that was just looking at Achilles tendinopathy. Now we're looking at plantar fasciitis, which I found a little bit more interesting because plantar fasciitis isn't a tendon. It behaves similar to a tendon, but it's fascia. So the thing about a tendon is the primary pathology isn't a lot of inflammation. So that's why we've changed our terminology from a tendonitis. which was a very common term in the 90s in the early 2000s. They've changed that to a tendinopathy now because the ITIS in tendonitis refers to inflammation. And so coming up with more understanding, or like I think some researchers are still scratching their heads about whether inflammation is a part of it, but there seems to be a general consensus that even if it is, it's not the primary driver. And so they changed it to from tendonitis to a tendinopathy. But plantar fasciitis, I'm not too sure how much inflammation actually plays a role, but this is fascia, it's different. So they say, limited cohort studies have shown promising results for the use of PRP in the setting of plantar fasciitis, with improvement noted in pain, functionality, and tissue integrity. Comparisons with corticosteroid injections suggest that PRP is at least as effective as corticosteroids and more effective than saline at reducing pain reduction in three months after the injection. So that's compared to corticosteroids seems to be just as effective and more effective than a placebo or a saline group. It seems to be like for the tendons, it seems to be a saline group. seems to get just as just as better. I think Peter Maliaris mentioned that on our podcast as well when I interviewed him. But yeah, so I think we're seeing a little skew in favor of plantar fasciitis here, but they don't say a whole lot. They continue. More extended comparative studies demonstrated improvements in pain and functionality up to two years. So good follow up good times. A recent systematic review and meta analyses included 10. prospective trials and found that PRP therapy provides greater pain relief compared with corticosteroids at three and six months after the injection. So I don't see anything when comparing to, um, exercise therapy, but, um, I don't think exercise therapy and strengthening is that strong when it comes to plantar fasciitis. I see good results with it, but, um, the research doesn't tend to bring it forth. Um, when I spoke to Ian Griffiths on the podcast about plantar fasciitis, he was like the same. He's like, yeah, I use exercise therapy all the time. Just the, the research hasn't shown it to be effective or hasn't had great, um, publications on it. So, um, I guess that's why it's not mentioned in this, but, um, nonetheless, like reading this, you can sort of get the, the overall paper design. seems to have that unbiased view you sort of get this is what it shows for benefit. But then again, these are the limitations and this is the biases are there. These are the small sample sizes. And this is compared to exercise alone. This is we're still scratching our heads a bit more inconclusive, but I don't know, just reading this, it seems like there's a slight sort of tilt towards plantar fasciae being more effective, but it sort of changes a little bit once we get into our second Um, was a little bit mixed. Um, just reading the paper, the title was application of orthobiologics in Achilles tendinopathy, a review. Um, and it was 2022. So last year, very recent and, um, just looking at Achilles tendinopathy for all of these orthobiologics, all these agents that are used and just reading it. You know, sometimes you can read things and just get a sense that they're not. not sharing everything, not telling the whole story and sort of maybe pushing an agenda. And this one not only just mentions papers, but it talks about like a lot about the theory, a lot about these are all the studies that talk about why it should work. It's all like tendinopathies have a certain way this is why they get sore. This is why they develop. There's a whole bunch of processes that go along with chronic tendinopathies, there's vascularization, there's thickening, they do mention some inflammation, which I'm not entirely sure. And then they say PRP and injectable should work because of this, they say that PRP reduces inflammation, tick PRP and other injectables do this tick and they're sort of like going through why it should work and all the reasons why it should work, but not studies that show it does work. in some circumstances, like there's half the page, half a paper of just talking about the theory. Nonetheless, they do mention some studies and mention some like reason for effectiveness, but I digress. So the first sentence of the paper is Achilles tendinopathy or tendonitis of the heel is one of the most common ankle and foot overuse injuries. First of all, they start, they use the term tendonitis, they say Achilles tendinopathy or tendonitis of the heel. Um, I don't know the fact that they use that the term tendonitis, which is outdated. I haven't seen that term in a paper in a recent paper for a long time. So I'm not sure why they use that, but I think as I kept reading, they kept, um, pushing the theory about inflammation being present, injectables, reducing inflammation. So I guess that's, um, they're trying to use that rationale. I scrolled down and it said, um, one of the headings was biologics and Achilles tendinopathy. So I decided to read that. I went down there was a whole bunch of stem cell ones and different type of stem cell injections, different types of injectables. And I just skipped to the PRP side because it seems to be more correlating with the topic of today. And I don't want this to go for two hours, nor do I want to read a whole bunch of paper for some stuff that's not really that relevant. So, um, I skipped, sorry, Laura, I skipped to the PRP stuff and they sort of rationalize in the paper, they say by concentrating platelets, the growth factors are released from alpha granules of platelets, which enhance the natural healing cascade PRP contains white blood cells and chemokines, which regulate inflammatory processes. So they're talking about PRP and like why it should work. Um, based on the properties that it has and based on the pathology that they're injecting it into. They talk about some outcomes. They say the outcome of PRP injection for Achilles tendonopathy demonstrates decreased vascularity and changes in tendon thickness as reports in a few studies, whereas a few researchers have provided controversial data stating the increased tendon thickness at three months follow-up. So they sort of mentioned in here, they say that Okay, there's some studies, they say a few studies that say that PRP has decreased vascularity, which as a tendon sort of becomes worse as the pathology tends to develop, they talk about this vascularity, which it starts to get like a little blood supply, it sort of starts to form all these little vessels, which the tendon doesn't want, it sort of becomes bit more disorganized and you know, we want the tendon to be nice and strong with this collagen fibers all aligned and that sort of stuff. And it sort of just becomes a bit messy, a bit yuck. And it says that it, this PRP is believed to decrease the vascularity and changes in the tendon thickness, which they talk about thickness in this paper a lot, and it sort of gives me the impression that they're really talking about chronic sort of Achilles tendon, all this stuff like really, really bad. had it for years, like mismanaged for a lot of years, and you sort of get that thickened appearance, which doesn't happen for everyone, but it seems to be that they're talking about the treatments of like really, really poor tendons. Anyway, because they said that they've shown it favorable in a few studies, I actually did some digging, because when they mentioned it, they go further in the paper and said, Deans et al, so they're talking about a paper from Deans. demonstrated a significant clinical improvement in Achilles tendinopathy with a single dose along with regular exercise and therapeutic ultrasound. So this statement seems to be that they're pushing the favor of yes, it does work. It seems like it's significant clinical improvement with a single dose, but then they also say along with regular exercise and that sort of stuff. So like I say, I did some digging. I went into the reference list, found that paper. opened up that paper and read that paper. And it said that the study design, when I found the study, it said, our objective was to assess whether this condition can be effectively treated with a treatment protocol of combining PRP injection, followed by a standardized rehab protocol, which involved being in a cast boot for six weeks, a therapeutic ultrasound treatment, and an eccentric exercise program. So it's, you know, they're just looking at that population and seeing if they get better. And there's so many things in there. There's the PRP, then there's the boot, then there's the ultrasound, then there's the eccentric exercise program, which me working with tendonopathies, I just do the exercise, eccentric exercise program alone and people get better. And so going back to this original paper and saying that, you know, this paper, has demonstrated a significant clinical improvement in Achilles tendinopathy with a single dose along with exercise and therapeutic ultrasound. You could read that and think, oh yeah, this looks promising without sort of digging deeper and working out what the actual study design was. So now that I found that study design and thought, you know, it doesn't really show much about revealing just PRP. Nonetheless, this original review Then concludes, despite controversy in the literature, many studies share the common ground in the sense that PRP consistently presents itself as a safe and effective biological agent for both chronic and acute Achilles tendon injuries with significant improvements in pain and function outcomes. So, I don't know, I'm yet to be convinced. But that's what they concluded. They concluded, yep, safe, effective, seems to decrease pain. But even when I dig a little bit deeper, I am yet to be convinced. But at the end of that conclusion, when they say safe, effective for chronic acute tendon injuries, pain, function improvements, they then reference a list of four references. And so I was about to hit, I was about to like start hitting chord. click finish on the typing that I had done. And I'm like, no, let me dig a little bit deeper because this overall statement to the end seems like they're pushing for PRP. They seem like, okay, studies are showing that it's favorable, but then they had these other four references at the end. So I'm like, okay, let me dig a bit deeper. And out of these four references, one of the papers was from Peter Maliaris was one of the co-authors. He wasn't a lead author, but he was one of the co-authors. And this is like probably the most promising one that I found. So I guess this is me trying to be my own unbiased sort of, host or presenter. Like I said at the start, I could easily find a paper that sort of favors PRP and not choose to talk about it. you know, this doesn't follow my particular philosophy or narrative and that sort of thing. And so, um, I couldn't, but you know, trying to be as unbiased as possible. I looked at this one, I'm like, you know, anything that has Peter Maliaris in it, I'm going to trust the sort of process and it's going to be good overall design. It's going to be like well balanced and even in its, um, judgments and its conclusions. And so the title was the effect of high volume injections. PRP and sham treatments on chronic mid-portion Achilles tendinopathy, a randomized double-blinded prospective study. I like the title of this. It's talking about injectables, talking about PRP, it's talking about sham treatments, that sort of isolating it to chronic mid-portion Achilles tendinopathy. So very precise. They use chronicers in like greater than three months and mid-portion being it's not an insertional tendinopathy. And then they say it's a randomized double blinded perspective study. So the researchers or the ones that are collecting the results, they're blinded, the patients they're blinded. So love it already. Um, and yeah, like I say, there's probably some promising stuff in here. It says that a total of 60 men. So yeah, the sample size is a lot better than a lot of the other studies we've been talking about with. chronic Achilles tendinopathy, like I say, that's more than three months, were included and followed up for six months within the study. And the outcomes were assessed at baseline. So outcomes, I think were just like pain function, all that sort of stuff. So they were assessed at baseline, and then at six, 12, and 24 weeks of follow up. So we're looking at a pretty good Pretty good follow up, I guess we could see 12 and 24 months, that would be quite nice, but you know, liking this already. All participants performed eccentric training combined with either. So everyone did eccentric stuff, but one group, there was three groups, one group got the high volume injection, which was a steroid or a saline or local anesthetic. They actually got four PRP injections every 14 days. So one injection every 14 days up to a total of four. And then the three was the placebo, which they just put a few drops of saline under the skin. So that's, I guess, how they can blind it because they're not telling anyone what they're getting. They're like, you're getting an injectable. Let's see how things go. Some people got. placebo, some people got different variations of high volume injections and some people got the PRP. So the outcomes included function and symptoms, self-reported tendon pain during activity, they looked at tendon thickness, they looked at the muscle function, which I saw was like the heel race tests, testing all these things. And their conclusion was the treatment with higher volume injections or PRP in combination with this 12 week eccentric program regime in chronic Achilles tendonopathy seems more effective in reducing pain, improving activity levels and reducing tendon thickness than the eccentric training alone. So we got there, we got a study that has moderate size, double blinded, you know, we could do a longer follow up. we want to see what that's like but seems to have been more effective combining some high volume injections or PRP and doing the eccentric program than just doing the eccentric program. We're seeing some, this study shows some benefits there. So we got there, I found one, which was nice and sort of continues to still scratch our heads because this is one RCT, Um, we are talking about just one and then if you combine it with all a whole bunch of other studies, we're then still getting conclusive, inconclusive results and sort of scratching our heads. But nonetheless, I thought I'd share that. Um, what I would do if a client came to me and said that I am, I have an, a tendinopathy and someone's recommending PRP, what should I do? Um, right now, as I'm recording this episode, I would say, let's just do the eccentric stuff. or let's just do loading first, let's see how things go. Because just what I have seen in my work, you get people, you load them up, you manage them properly and they get better. I see most in 12 weeks would be totally fine. But the idea is if someone comes to me, they've done all the right things, I actually dig deep and see that they've done all the right things and it's quite chronic and it's thickened and... they're saying my medical team wants me to do PRP, what should I do? You know, I would say weigh up your risks, but maybe it's an option for you. But keep in mind, it's not just the, um, it's not just the PRP. We need to also continue with this strength exercises and strengthening to restore the capacity. Cause that's another thing as well. When it comes to tendon, um, rehab, it is all about raising the capacity of that tendon to get it back to what you need to, which in our case, it's running, it's running a marathon, it's, you know, hills and sprints and all that sort of stuff. An injection, an injection doesn't do anything to raising the capacity of a tendon, which is why I'm a bit annoyed based on, like I say, prior to this episode, prior to talking about the papers, you know, I haven't been that enthused when it comes to PRP. Uh, because I see a lot of people just pushing a lot of health professionals and like, um, orthopedic surgeons or, um, specialists just pushing a PRP without any discussion of strength or, you know, restoring the capacity. So it does seem that it may work for some, may work for some chronic, thickened tendons. It does need to be accompanied with a strength program. So I started off this episode thinking. you know, we're going to get to the end and it's going to be, it depends. It's going to, we're not going to have any definitive answers, but hopefully enjoy the journey. Um, but you know, we can walk away with some better understanding. I think I have a better understanding after reading these papers. So, um, thanks Laura for sharing this. Um, anyone else who has a paper that you want me to review, I'll have a look at it and, um, see if it's worthy of a, an episode. Um, I do have a few other papers in the pipeline. I've been quite, um, Slack on Twitter these days, over the last couple of months, which is where I get my insights and my papers from, but I'm back on them now and finding some really cool ones, looking at like strength training to improve running economy, looking at shoes that have the best performance, looking at someone did a strength program and foam rolling program for 18 weeks to see what happens and yeah, looking to share those out. So if you like these sorts of formats, let me know. I do. recognize that sometimes it does get a bit convoluted. I think my idea is to share literature can get a bit dry sometimes, but it's hard to really, you know, make it exciting. Anyway, nonetheless, I hope you enjoyed this episode. Thanks once again for listening and taking control of your rehab. If you are a runner and love learning through the podcast format, then go ahead and check out the Run Smarter podcast hosted by me. I'll include the link along with all the other links mentioned today in the show notes. So open up your device, click on the show description, and all the links will be there waiting for you. Congratulations on paving your way forward towards an empowering, pain-free future, and remember, knowledge is power.