Review article
Tendinopathy in athletes

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Abstract

Overuse related tendon pain is a significant problem in sport and can interfere with and, in some instances, end an athletic career. This article includes a consideration of the biology of tendon pain including a review of tendon anatomy and histopathology, risk factors for tendon pain, semantics of tendon pathology, and the pathogenesis of tendon pain. Evidence is presented to guide the physical therapist in clinical decision-making regarding the examination of and intervention strategies for athletes with tendon pain.

Introduction

Overuse related tendon pain is a very common condition in sport. Kannus (1997, p. 53) wrote that tendon pain is a “source of major concern in recreational and competitive athletes”. Overuse injuries are more common than macrotraumatic injuries in athletics (Brukner & Bennell, 1997), and much of overuse injury is tendon related. Tendon pain is frequently reported in sports including volleyball, basketball, long distance running, and jumping events in track and field (Ferretti et al., 1985, Jarvinen et al., 2005, Kujala et al., 2005, Lian et al., 2005, Taunton et al., 2002). The tendons most commonly susceptible to overuse injuries are the patellar, Achilles, posterior tibialis, rotator cuff, long head of the biceps brachii, and the wrist extensors (Maffulli, Wong et al., 2003, Rees et al., 2006).

Section snippets

Tendon histology

The function of a tendon is to attach muscle to bone, thereby transferring force of the contracting muscle to bone and either inducing or controlling movement. The efficiency of this force transfer is maximized by minimal elasticity of the tendon. When muscular contraction occurs, the tendon is subjected to tensile loading. This results in the storage of elastic energy within the tendon. As human tendons demonstrate minimal hysteresis, most of the elastic energy stored in the tendon is released

Risk factors for tendon pain

There is evidence that some individuals may be more at risk for developing tendon pain than others. These risk factors are classified as intrinsic (within the body) or extrinsic (outside the body) and modifiable or non-modifiable. Intrinsic non-modifiable risk factors include increasing age (Astrom, 1998, Birch et al., 2001, Riley et al., 2001, Sargon et al., 2005, Tuite et al., 1997), gender (Ashford et al., 2002, Astrom, 1998, Astrom and Rausing, 1995, Holmes and Lin, 2006, Knobloch et al.,

Semantics of tendon pathology

One of the issues that have contributed to confusion in understanding tendon pain is the multiple terms associated with tendon pain. Bernstein (2006) wrote in an editorial on linguistic determinism in medicine that “the names of the diseases, one might argue, set the bounds on our thought, possibly to the detriment of patients.” One example he used in that editorial was the rather indiscriminate use of the term “tendinitis” for all tendon pain. Tendinitis describes a specific histopathological

Pathogenesis of tendinopathy

The controversy pertaining to the pathogenesis of tendinopathy and the inflammatory pathway is one that has persisted. Fredberg and Stengaard-Pedersen (2008) challenged the tendinitis myth with recent evidence that pro-inflammatory agents are present in chronic tendinopathies, and the rapid response to corticosteroid intervention. These authors described a “tendinopathic iceberg” (Fig. 3) with a long period of time of asymptomatic changes in tendon with the exposed tip of the iceberg being a

Clinical examination of the athlete with a painful tendon

In the clinical examination of an athlete with a painful tendon, taking a thorough history is crucial. Leadbetter (1992) emphasized the significance of the “principle of transitions” for athletes with overuse injury. This principle states that injury is most likely when an athlete has made some kind of training change including training routine (intensity, frequency, duration), training surface, equipment, or technique. Accordingly, taking the history must include questions that provide the

Intervention for the painful tendon

The intervention plan for an athlete with tendon pain should be based on an integration of the clinician’s clinical judgment, the patient’s values, and the best available evidence (Sackett, 2000). Although tendinopathy is a common condition in athletes, there are few randomized controlled trials that have investigated the interventions recommended for athletes with tendon pain. Consequently, clinical reasoning is crucial in linking restrictions in daily and sport activities with impairments in

Conclusion

Tendon pain is a common condition seen by sports medicine health care professionals. At this time, the evidence suggests that while tendon pain may have an early inflammatory stage, much of what is seen is not a primary inflammatory problem but one characterized by tendon disrepair and degeneration. The treatment of tendon pain is multifactorial and thereby challenging and requires careful consideration of the chronicity of the problem and the athlete-specific impairments associated with the

Conflict of interest

There are no conflicts of interest for the author of this manuscript.

Funding

No external funding was used in this research.

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