Abstract
Tendons behave viscoelastically and exhibit adaptive responses to conditions of increased loading and disuse. High-resolution, real-time ultrasound scanning confirms the applicability of these findings in human tendons in vivo. In addition, recent biomechanical studies indicate that strain patterns in tendons may not be uniform, as tendons show stress-shielded areas and areas subjected to compressive loading at the enthesis. These areas correspond to the sites where tendinopathic characteristics are typically seen. This indicates that some tendinopathies may, paradoxically, be considered as ‘underuse’ lesions despite the common beliefs that they are overuse injuries. Classic inflammatory changes are not frequently seen in chronic athletic tendon conditions and histopathology features in tendinopathic tendons are clearly different from normal tendons, showing an exaggerated dysfunctional repair response. Tendinopathies are traditionally considered overuse injuries, involving excessive tensile loading and subsequent breakdown of the loaded tendon. Biomechanical studies show that the strains within the tendons near their insertion site are not uniform. If the material properties are similar throughout the tendon, forces transferred through the insertion site preferentially load the side of the tendon that is usually not affected initially in tendinopathy. In that case, the side affected by tendinopathy is generally ‘stress shielded’. Thus, the presence of differential strains opens the possibility of alternative biomechanical explanations for the pathology found in these regions of the tendon. The traditional concept of tensile failure may not be the essential feature of the pathomechanics of insertional tendinopathy. Certain joint positions are more likely to stress the area of the tendon commonly affected by tendinopathy. Incorporating different joint position exercises may exert more controlled stresses on these affected areas of the tendon, possibly allowing better maintenance of the mechanical strength of that tendon region and, therefore, prevent injury. Such exercises could stress a healing area of the tendon in a controlled manner and thus stimulate healing once an injury has occurred. Additional work is needed to prove whether such principles should be incorporated in current rehabilitation techniques.
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References
Kujala UM, Kvist M, Osterman K. Knee injuries in athletes: review of exertion injuries and retrospective study of outpatients sports clinic material. Sports Med 1986; 3: 447–60
Renstrom P. Sports traumatology today: a review of common current sports injury problems. Ann Chir Gynaecol 1991; 80: 81–93
Zajac FE. Muscle and tendon: properties, models, scaling, and application to biomechanics and motor control. CRC Crit Rev Biomed Eng 1989; 17: 359–411
Rack PMH, Ross HF. The tendon of flexor pollicis longus: its effects on the muscular control of force and position at the human thumb. J Physiol 1984; 351: 99–110
Alexander RM. Elastic mechanisms in animal movement. Cambridge: Cambridge University Press, 1988
Wilson AM, Goodship AE. Exercise-induced hyperthermia as a possible mechanism for tendon degeneration. J Biomech 1994; 27: 899–905
Viidik A. Functional properties of collagenous tissues. Int Rev Connect Tissue Res 1973; 6: 127–215
Butler DL, Goods ES, Noyes FR, et al. Biomechanics of ligaments and tendons. Exerc Sports Sci Rev 1978; 6: 125–81
Ker RF. Tensile fibres: strings and straps. In: Vincent JFV, editor. Biomechanics: materials — a practical approach. New York: Oxford University Press, 1992: 75–97
Rigby BJ, Hirai N, Spikes JD, et al. The mechanical properties of rat tail tendon. J Gen Physiol 1959; 43: 265–83
Partington FR, Wood GC. The role of noncollagen components in the mechanical behaviour of tendon fibres. Biochem Biophys Acta 1963; 69: 485–95
Elliott DH. Structure and function of mammalian tendon. Biol Rev Camb Philos Soc 1965; 40: 392–41
Diamant J, Keller A, Baer E, et al. Collagen: ultrastructure and its relations to mechanical properties as a function of ageing. Proc R Soc Lond B Biol Sci 1972; 180: 293–315
Bennett MB, Ker RF, Dimery NJ, et al. Mechanical properties of various mammalian tendons. J Zool Lond 1986; 209: 537–48
Shadwick RE. Elastic energy storage in tendons: mechanical differences related to function and age. J Appl Physiol 1990; 68: 1033–40
Pollock CM, Shadwick RE. Relationship between body mass and biomechanical properties of limb tendons in adult mammals. Am J Physiol 1994; 266: R1016–21
Cohen RE, Hooley CJ, McCrum NG. Viscoelastic creep of collagenous tissue. J Biomech 1976; 9: 175–84
Hooley CJ, McCrum NG, Cohen RE. The viscoelastic deformation of tendon. J Biomech 1980; 13: 521–8
Cumming WG, Alexander RM, Jayes AS. Rebound resilience of tendons in the feet of sheep. J Exp Biol 1978; 74: 75–81
Ker RF, Alexander RM, Bennett MB. Why are mammalian tendons so thick? J Zool Lond 1988; 216: 309–24
Woo SL-Y, Gomez MA, Woo Y-K, et al. Mechanical properties of tendons and ligaments II: the relationships of immobilization and exercise on tissue remodelling. Biorheology 1982; 19: 397–408
Savolainen J, Myllyla V, Myllyla R, et al. Effects of denervation and immobilization on collagen synthesis in rat skeletal muscle and tendon. Am J Physiol 1984; 254: R897–902
Vailas AC, Deluna DM, Lewis LL, et al. Adaptation of bone and tendon to prolonged hindlimb suspension in rats. J Appl Physiol 1988; 65: 373–6
Loitz BJ, Zernicke RF, Vailas AC, et al. Effects of short-term immobilization versus continuous passive motion on the biomechanical and biochemical properties of rat tendon. Clin Orthop 1989; 224: 265–71
Viidik A. Age-related changes in connective tissues. In: Viidik A, editor. Lectures on gerontology. London: Academic, 1982: 173–211
Barnard K, Light ND, Sims TJ, et al. Chemistry of the collagen cross-links: origin and partial characterization of a putative mature cross-link of collagen. Biochem J 1987; 244: 303–9
Woo SL-Y, Ritter MA, Amiel D, et al. The biomechanical and biochemical properties of swine tendons: long term effects of exercise on the digital extensors. Connect Tissue Res 1980; 7: 177–83
Tipton CM, Vailas AC, Matthes RD. Experimental studies on the influence of physical activity on ligaments, tendons and joints: a brief review. Acta Med Scand Suppl 1986; 71: 157–68
Johnson GA, Tramaglini DM, Levine RE, et al. The tensile and viscoelastic properties of human patellar tendon. J Orthop Res 1994; 12: 796–803
Blevins FT, Hecker AT, Bigler GT, et al. The effects of donor age and strain rate on the biomechanical properties of bone-patellar tendon-bone allografts. Am J Sports Med 1994; 22: 328–33
Hubbard RP, Soutas-Little RW. Mechanical properties of human tendon and their age dependence. J Biomech Eng 1984; 106: 144–50
Vogel HG. Influence of maturation and ageing on mechanical and biochemical properties of connective tissue in rats. Mech Ageing Dev 1980; 14: 283–92
Vogel HG. Age dependence of mechanical properties of rat tail tendons (hysteresis experiments). Aktuelle Gerontol 1983; 13: 22–7
Speed CA. Corticosteroid injections in tendon lesions. BMJ 2001; 3183: 382–6
Phelps D, Sonstegard DA, Matthews LS. Corticosteroid injection effects on the biomechanical properties of rabbit patellar tendons. Clin Orthop 1974; 100: 345–8
Wood TO, Cooke PH, Goodship AE. The effect of anabolic steroids on the mechanical properties and crimp morphology of the rat tendon. Am J Sports Med 1988; 16: 153–8
Noyes FR, Grood ES, Nussbaum NS, et al. Effect of intraarticular corticosteroids on ligaments properties: a biomechanical and histological study in rhesus knees. Clin Orthop 1977; 123: 197–209
Matthews LS, Ellis D. Viscoelastic properties of cat tendon: effects of time after death and preservation by freezing. J Biomech 1968; 1: 65–71
Smith CW, Young IS, Kearney JN. Mechanical properties of tendons: changes with sterilization and preservation. J Biomech Eng 1996; 118: 56–61
Lieber RL, Leonard ME, Brownn CC, et al. Frog semitendinosis tendon load-strain and stress-strain properties during passive loading. Am J Physiol 1991; 30: C86–92
Trestik CL, Lieber RL. Relationship between Achilles tendon mechanical properties and gastrocnemius muscle function. J Biomech Eng 1993; 115: 225–30
Maganaris CN, Paul JP. In vivo human tendon mechanical properties. J Physiol 1999; 521: 307–13
Maganaris CN, Paul JP. Hysteresis measurements in intact human tendon. J Biomech 2000; 33: 1723–7
Maganaris CN, Paul JP. Tensile properties of the in vivo human gastrocnemius tendon. J Biomech 2002; 35: 1639–46
Kubo K, Kanehisa H, Fukunaga T. Effects of different duration isometric contractions on tendon elasticity in human quadriceps muscles. J Physiol 2001; 536: 649–55
Kubo K, Kanehisa H, Kawakami Y, et al. Influence of static stretching on viscoelastic properties of human tendon structures in vivo. J Appl Physiol 2001; 90: 520–7
Muramatsu T, Muraoka T, Takeshita D, et al. Mechanical properties of tendon and aponeurosis of human gastrocnemius muscle in vivo. J Appl Physiol 2001; 90: 1671–8
Magnusson SP, Aagaard P, Rosager S, et al. Load-displacement propertries of the human triceps surae aponeurosis in vivo. J Physiol 2001; 531: 277–88
Bojsen-Moller J, Hansen P, Aagaard P, et al. Measuring mechanical properties of the vastus lateralis tendon-aponeurosis complex in vivo by ultrasound imaging. Scand J Med Sci Sports 2003; 13: 259–65
Maganaris CN, Baltzopoulos V, Sargeant AJ. Repeated contractions alter the geometry of human skeletal muscle. J Appl Physiol 2002; 93: 2089–94
Maganaris CN. Tendon conditioning: artifact or property? Proc R Soc Lond B Biol Sci 2003; 270Suppl. 1: S39–42
Maganaris CN. In vivo tendon mechanical properties in young adults and healthy elderly [online]. In: Proceedings of the Research Symposium on Plasticity of the Motor System: Adaptation to Increased Use, Disuse and Ageing; 2001 Apr 6; Manchester. Available from URL: http://www.mmu.ac.uk/c-a/exspsci/alsymp.html [Accessed 2004 Oct 18]
Reeves ND, Maganaris CN, Ferretti G, et al. Influence of long-term bed rest on muscle architecture and tendon mechanical properties. J Physiol 2002; 543: 103
Reeves ND, Maganaris CN, Narici MV. Effect of strength training on human patella tendon mechanical properties of older individuals. J Physiol 2003; 548: 971–81
Reeves ND, Narici MV, Maganaris CN. Strength training alters the viscoelastic properties of tendons in elderly humans. Muscle Nerve 2003; 28: 74–81
Komi PV, Fukashiro S, Jarvinen M. Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med 1992; 11: 521–31
Jozsa LG, Kannus P. Spontaneous rupture of tendons. In: Jozsa LG, Kannus P, editors. Human tendons: anatomy, physiology and pathology. Champaign (IL): Human Kinetics, 1997: 254–325
Pike AVL, Ker RF, Alexander RM. The development of fatigue quality in high-and low-stressed tendons of sheep (Ovis aries). J Exp Biol 2000; 203: 2187–93
Magnusson SP, Hansen P, Aagaard P, et al. Differential strain patterns of the human gastrocnemius aponeurosis and free tendon, in vivo. Acta Physiol Scand 2003; 177: 185–95
Ito M, Kawakami Y, Ichinose Y, et al. Nonisometric behavior of fascicles during isometric contractions of a human muscle. J Appl Physiol 1998; 85: 1230–5
Astrom M, Rausing A. Chronic Achilles tendinopathy: a survey of surgical and histopathological findings. Clin Orthop 1995; 316: 151–64
Chard MD, Cawston TE, Riley GP, et al. Rotator cuff degeneration and lateral epicondylitis: a comperative histological study. Ann Rheum Dis 1994; 53: 30–4
Regan W, Wold LE, Coonrad R, et al. Mircroscopic histopathology of chronic refractory lateral epicondylitis. Am J Sports Med 1992; 20: 746–9
Khan KM, Cook J, Bonar F, et al. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999; 27: 393–408
Kader D, Saxena A, Movin T, et al. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 2002; 36: 239–49
Maffulli N, Kader D. Tendinopathy of tendo Achillis. J Bone Joint Surg Br 2002; 84: 1–8
Leadbetter WB. Cell-matrix response in tendon injury. Clin Sports Med 1992; 11: 533–78
Clement DB, Taunton JE, Smart GW. Achilles tendonitis and peritendinitis: etiology and treatment. Am J Sports Med 1984; 12: 179–84
Korkia PK, Tunstall-Pedoe DS, Mafulli N. An epidemiologic investigation of training and injury patterns in British triathletes. Br J Sports Med 1994; 28: 191–6
Ilfeld FW. Can stroke modification relieve tennis elbow? Clin Orthop 1992; 276: 182–6
Kibler WB, Chandler TJ, Pace BK. Principles of rehabilitation after chronic tendon injuries. Clin Sports Med 1992; 11: 661–71
James SL. Running injuries to the knee. J Am Acad Orthop Surg 1995; 3: 309–18
Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg 1994; 2: 1–8
Almekinders LC. Tendinitis and other chronic tendinopathies. J Am Acad Orthop Surg 1998; 6: 157–64
Herring SA, Nilson KL. Introduction to overuse injuries. Clin Sports Med 1987; 6: 225–39
Woo S-L. Mechanical properties of tendons and ligaments I: quasi-static and non-linear viscoelastic properties. Biorheology 1982; 19: 385–96
Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987; 15: 168–71
Popovich RM, Gardner JW, Potter R, et al. Effect of rest from running on overuse injuries in army basic training. Am J Prev Med 2000; 18: 147–55
Witvrouw E, Bellemans J, Lysens R, et al. Intrinsic risk factors for the development of patellar tendonitis in an athletic population: a two-year prospective study. Am J Sports Med 2001; 29: 190–5
Hartig DE, Henderson JM. Increased hamstring flexibility decreases lower extremity overuse injuries in military basic trainees. Am J Sports Med 1999; 27: 173–6
Soderman K, Alfredson H, Pietila T, et al. Risk factors for leg injuries in female soccer players: a prospective investigation during one out-door season. Knee Surg Sports Traumatol Arthrosc 2001; 9: 313–21
MacLellan GE, Vgvyan B. Management of pain beneath the heel and Achilles tendonitis with viscoelastic heel inserts. Br J Sports Med 1984; 15: 117–21
Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles: a prospective study. Am J Sports Med 1990; 18: 636–41
Kannus P, Niittymaki S, Jarvinen M, et al. Sports injury in elderly athletes: a three-year prospective, controlled study. Age Ageing 1989; 18: 263–70
Fahlstrom M, Lorentzon R, Alfredson H. Painful conditions in the Achilles tendon region: a common problem in middle-aged competitive badminton players. Knee Surg Sports Traumatol Arthrose 2002; 10: 57–60
Almekinders LC, Gilbert JA. Healing of experimental muscle strains and the effects of anti-inflammatory medication. Am J Sports Med 1986; 14: 303–8
Garrett WE. Muscle strain injuries: clinical and basic aspects. Med Sci Sports Exerc 1990; 22: 436–43
Kjellin I, Ho CP, Cervilla V, et al. Alterations in the supraspinatus tendon at MR imaging: correlation with histopathologic findings in cadavers. Radiology 1991; 181: 837–41
Meyerson MS, Garvey W. Disorders of the insertion of the Achilles tendon. J Bone Joint Surg 1998; 80A: 1814–24
Potter HG, Hannafin JA, Morwessel RM, et al. Lateral epicondylitis: correlation of MR imaging, surgical, and histopathologic findings. Radiology 1995; 196: 43–6
Shalaby M, Almekinders LC. Patellar tendonitis: the significance of magnetic resonance imaging findings. Am J Sports Med 1999; 27: 345–9
Andrews JR, Broussard TS, Carson WG. Arthroscopy of the shoulder in the management of partial tears of the rotator cuff: a preliminary report. Arthroscopy 1985; 1: 117–22
Baker CL, Murphy KP, Gottlob CA, et al. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg 2000; 9: 475–82
Griffiths GP, Selesnick FH. Operative and arthroscopic findings in chronic patellar tendonitis. Arthoscopy 1998; 14: 836–9
Rufai A, Ralphs JR, Benjamin M. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res 1995; 13: 585–93
Benjamin M, Evans EJ, Copp L. The histology of tendon attachments to bone in man. J Anat 1986; 149: 89–100
Vogel KG, Ordog A, Pogany G, et al. Proteoglycans in the compressed region of the human tibialis posterior ten don and in ligaments. J Orthop Res 1993; 11: 68–77
Bey MJ, Kwon Song H, Wehrli FW, et al. Intratendinous strain fields of the intact supraspinatus tendon: the effect of glenohumeral joint position and tendon region. J Orthop Res 2002; 20: 869–74
Almekinders LC, Vellema JH, Weinhold PS. Strain patterns in the patellar tendon and the implications for patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc 2002; 10: 2–5
Basso O, Amis AA, Race A, et al. Patellar tendon fiber strain: their differential responses to quadriceps tension. Clin Orthop 2002; 400: 246–53
Basso O, Amis AA, Johnson DP. Biomechanical analysis of surgical procedures for patellar tendonitis. Proceedings of the 10th Congress of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy; 2002 Apr 23–27; Rome, 145
Almekinders LC, Lyman J, Weinhold PS. LC. Strain patterns in the Achilles tendon: implications for tendinopathy. Proceedings of the 10th Congress of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy; 2002 Apr 23–27; Rome, 14
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Maganaris, C.N., Narici, M.V., Almekinders, L.C. et al. Biomechanics and Pathophysiology of Overuse Tendon Injuries. Sports Med 34, 1005–1017 (2004). https://doi.org/10.2165/00007256-200434140-00005
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DOI: https://doi.org/10.2165/00007256-200434140-00005