Peter Malliaras: Scans, Strength, PRP, Injections & Shockwave

Proximal Hamstring Tendinopathy: An Expert’s Insights


In this podcast episode, we delve into the world of tendinopathy with renowned researcher and clinician, Dr. Peter Maliaris. Dr. Maliaris has dedicated 15 years of his career to the study of tendinopathy, holding a PhD in the field and conducting extensive postdoctoral research in the UK and Australia. In this discussion, we explore his research, the current state of tendinopathy management, the relevance of scans, and answer some pressing questions from our Facebook group members.

Dr. Peter Maliaris: A Journey into Tendinopathy

From Physio to Tendinopathy Expert

Dr. Maliaris began his career as a physiotherapist, practicing for approximately five years. A natural skeptic, he questioned the effectiveness of his methods and decided to embark on a research journey by pursuing a PhD. This choice was driven by his growing interest in tendinopathy, which has become his passion over the years.

Understanding Tendinopathy Pathology

Dr. Maliaris’s earlier research focused on understanding tendinopathy pathology, particularly how imaging reveals changes over time. He collaborated with Jill Cook, a prominent figure in the field, to develop a continuum model that reshapes our thinking about tendinopathy progression. This work set the stage for a deeper understanding of pathology and pain.

Current Research: Exercise and Education

Presently, Dr. Maliaris’s research leans towards exercise and education. His work involves conducting trials to optimize interventions in tendinopathy management. Additionally, he operates a biomechanics lab at Clayton campus in Monash, where he investigates impairments related to rate of force development, strength, and balance. His goal is to tailor interventions based on these impairments.

The Importance of Education in Pain Management

One significant revelation in recent years has been the need for better education in pain management. Dr. Maliaris has dedicated time to develop education interventions tailored to the specific needs of tendinopathy patients. This is particularly relevant in cases like rotator cuff-related pain, where targeted education can enhance outcomes.

Proximal Hamstring Tendinopathy: A Visual Learning Opportunity

In addition to the podcast, Dr. Maliaris offers a video course for proximal hamstring tendinopathy. This visual resource complements the audio content, providing in-depth insights, rehabilitation exercises, and visual aids to enhance understanding. The course is accessible through the Run Smarter app, and podcast listeners can enjoy a 50% discount via the provided link.

The Evolving Landscape of Tendinopathy Management

In the past decade, some interesting developments have emerged in the field of tendinopathy. Dr. Maliaris points out that while there haven’t been revolutionary changes, one noteworthy trend was the focus on isometric exercises. In 2013, a study demonstrated that isometrics effectively reduce short-term pain and reverse inhibition in the brain’s motor cortex. This sparked interest and utilization of isometrics. However, ongoing research indicates that progressive loading may yield similar results, challenging the initial enthusiasm.

A Cautionary Note on Shockwave, PRP, and Injectables

When it comes to treatments like shockwave therapy, platelet-rich plasma (PRP), and other injectables, Dr. Maliaris underscores the importance of distinguishing them from placebos. Some studies show these treatments to be no more effective than placebos, while others suggest a potential benefit. The context and comparison of treatments matter significantly. Placebo comparisons remain crucial for understanding the true effectiveness of these interventions.

The Role of Imaging in Diagnosis

Dr. Maliaris advocates that the diagnosis of tendinopathy does not require imaging. Clinicians can confidently diagnose tendinopathy based on clinical assessments, pain behavior, aggravating factors, and physical tests. Imaging becomes relevant when initial treatments prove ineffective, potentially leading to alternative interventions or ruling out other issues. It is essential to remember that scans may reveal age-related changes that are not necessarily related to pain or pathology.

Differential Diagnosis and Surrounding Structures

Tendons often coexist with other structures such as fat pads, bursae, and adjacent tendons. In the case of Achilles tendinopathy, for example, scans may reveal changes in these surrounding tissues. Additionally, tendinopathy pain can involve multiple tissues, as demonstrated by the emphasis organ concept. While individualized treatment may account for some differences, the core of rehabilitation remains focused on progressive loading and exercise, irrespective of surrounding structures.

Personalized Management for Chronic Tendinopathy

For those with chronic tendinopathy, personalized management is essential. Dr. Maliaris emphasizes that treatment depends on the individual’s pain, function, and clinical presentation. Regardless of whether the condition has persisted for two weeks or several years, the approach involves targeting specific symptoms, such as pain, weakness, or fear avoidance behaviors. The goal is to minimize symptoms and progressively reintegrate the individual into their normal activities.

Managing Fear and Anxiety in Tendinopathy

Fear and anxiety about movement are common among individuals with tendinopathy, especially those with long-standing cases. Dr. Maliaris advises clinicians to play a crucial role in addressing these concerns. Effective communication and education can help patients understand that pain doesn’t necessarily correlate with tissue damage and that loading, even if uncomfortable, is part of the healing process. The reassurance provided by clinicians can be invaluable in alleviating these fears.

Scans and Diagnosis: Subheading: The Role of Scans in Diagnosis

Dr. Maliaris emphasizes that scans are not always necessary for diagnosis. Clinicians can often rely on clinical tests to accurately diagnose proximal hamstring tendinopathy, reducing unnecessary anxiety associated with scan results.

Strength and Progressive Rehabilitation: Subheading: The Significance of Strength

Strength and progressive rehabilitation take center stage in the management of tendinopathy. Regardless of how long you’ve had the condition, the core principles of rehab remain consistent. The key is to tailor your strength and loading regimen based on pain levels and functional capacity.

Pain vs. Weakness: Subheading: The Complex Relationship Between Pain and Weakness

A crucial point to note is that pain doesn’t always correlate with weakness. It’s essential to evaluate the tendon’s tolerance and strength through a structured strengthening program.

Patience and Mindset: Subheading: The Art of Patience

Dr. Maliaris leaves us with a valuable message: “Do the simple things really well and be patient.” Impatience can hinder progress in tendinopathy management. Maintaining a positive mindset and sticking to a well-structured plan is key to success.


Proximal hamstring tendinopathy is a complex condition that requires a multifaceted approach to management. Dr. Peter Maliaris’s extensive expertise and research in tendinopathy shed light on various aspects of this condition, from diagnosis to treatment. It’s evident that tendinopathy management is not a one-size-fits-all approach. The focus on patient education, reassurance, and tailored exercises remains crucial in guiding individuals towards recovery, regardless of the duration of their condition. While tendinopathy management may not have witnessed groundbreaking changes in recent years, ongoing research continues to refine our understanding and improve outcomes.