[ editorial
Not All Tendons Are Created
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Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®
]
Equal: Implications for Differing
Treatment Approaches
LORI A. MICHENER, PT, PhD, ATC, SCS, FAPTA
Division of Biokinesiology and Physical Therapy,
University of Southern California, Los Angeles, CA.
KORNELIA KULIG, PT, PhD, FAPTA
Division of Biokinesiology and Physical Therapy,
University of Southern California, Los Angeles, CA.
J Orthop Sports Phys Ther 2015;45(11):829-832. doi:10.2519/jospt.2015.0114
T
he majority of muscles have distinct tendinous attachments to
bones; however, only a few tendons develop painful conditions.
That simple observation prompts us to ask a few questions.
Are there commonalities in morphology and pathology
among the painful tendons? What contributes to the propensity for
pathology in some, but not all, tendons? And, consequently, should
all tendinopathies be managed equally? Two common tendinopathies
are those affecting the Achilles and supra-
spinatus, which are presented in this spe-
cial issue and serve as excellent models to
discuss similarities and contrasts.15,28
First things first: about the term ten-
dinopathy. Tendinopathy indicates a
disorder of the tendon. Tendinosis specif-
ically identifies the tendon pathology as a
long-standing degenerative chronic pro-
cess, whereas the traditional tendinitis
label implies that there is a predominant
inflammatory process. The histological
presence of inflammation has largely
been discounted as a primary feature of
tendon pathology; however, this long-
held dogma has been called into ques-
tion by some evidence of inflammation
with tendinopathy.9,24,26 Tendinopathy is
a less specific label and is likely best until
we know more about the pathology. This
journal of orthopaedic & sports physical therapy | volume 45 | number 11 | november 2015 |
45-11 Editorial5-Michener.indd 829
special issue of JOSPT focuses on this
complex topic of tendinopathy.
Commonalities (or Lack Thereof)
in Morphology and Pathology
Among Painful Tendons
Both the Achilles and supraspinatus ten-
dons serve to transfer tension from their
respective muscle to their bony attachment.
That may be where the similarities end. The
Achilles tendon is round and distinct from
surrounding structures. Conversely, the
supraspinatus tendon is flat and wide and
blends into the glenohumeral joint capsule.
This reflects the diversity in morphology
that can be found among tendons that are
common sites of tendinopathy. When look-
ing at this diversity, no single characteristic
emerges as a key factor common to the de-
velopment of tendon pain and pathology.
The extent and type of tendon vas-
cularity have been implicated as factors
contributing to a tendon’s poor healing
capacity and pain. Tendons are hypovas-
cular; however, the extent of vascularity
is not universally the same. Tendons with
less vascularity may be more vulnerable
to progressive degeneration and have
reduced healing potential. For the supra-
spinatus tendon, aging is related to both
decreased vascularity10 and increased
tendon degeneration and prevalence of
full-thickness tears. A different aspect of
vascularity explored with tendinopathy is
neovascularization. Neovascularization,
new vessel formation within the tendon,
is considered abnormal and presumed to
indicate tendon pathology. Neovascular-
ization has been reported in those with
Achilles tendinopathy and has been theo-
rized to be associated with neoinnerva-
tion, a potential source of pain. However,
there is limited evidence for a relation-
ship between neovascularization and
pain or clinical prognosis.30 In supraspi-
natus tendinopathy, neovascularization
has been less examined, and the findings
are equivocal for its presence.11,16 To date,
neither vascularity nor neovascularity
829
10/21/2015 4:47:21 PM

appears to be a key factor to explain the
commonality, or lack thereof, and clinical
presentation of tendon pathology.
When a tendon shows signs of degen-
eration and becomes a tendinosis, there
are similarities between the Achilles
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and supraspinatus tendons. The consis-
tent traits are fibroblastic degeneration
and disarray of collagen fibers, hyper-
cellularity, increased water content, and
higher ratio of collagen types III to I.31
Also, both tendons become structurally
thicker.14,20,23 Over time, the Achilles typi-
cally remains thicker. However, the su-
praspinatus tendon reverses course and
becomes thinner, with a loss of collagen
fiber structure that in part is consistent
with the increased prevalence of full-
thickness tears with aging.
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Can interventions address these
morphological alterations and lead to
remodeling of the tendon? A better un-
derstanding of tendon pathology would
further inform treatment decision mak-
ing about a management-and-exercise
approach to improve pain and function
and prevent recurrence. Further mecha-
nistic studies, likely tendon specific, are
Journal of Orthopaedic & Sports Physical Therapy®
desperately needed to understand why
tendinopathy develops and persists to
become a chronic degenerative condition
with repetitive painful episodes. Until we
have a better understanding of “why” and
of the related distinctions among ten-
dons, we will be left taking “shots in the
dark” when developing new strategies for
clinical management.
Propensity for Pathology in Some,
But Not All, Tendons
Tendinopathy predominantly develops
from excessive compression, tensile load,
or a combination. For both the Achilles
and supraspinatus, tensile load is applied
from their respective muscle(s) or with
strain during lengthening. Compression
loads are different for the 2 tendons. In
the case of the Achilles, compression
occurs distally over the calcaneal bony
protuberance—known as insertional ten-
dinopathy. For the supraspinatus, com-
pression occurs in the subacromial space.
830 | november 2015 | volume 45 | number 11 | journal of orthopaedic & sports physical therapy
45-11 Editorial5-Michener.indd 830
[ editorial ]
However, the prevalence of a compres-
sion mechanism for the supraspinatus is
less frequent than initially proposed, and
not likely the predominant mechanism.18
This has led to the evolution in terminol-
ogy from subacromial impingement syn-
drome to the label of subacromial pain
syndrome. Now the question is, “How can
we determine the cause(s) of too much
tendon load?”
Tendons are not inert structures.
They play a crucial role in locomotion as
energy-storing structures (eg, Achilles),1
and during control and positioning of
the glenohumeral joint during reaching
activities as positional tendons (ie, su-
praspinatus). For that reason, we suggest
that the best place to seek causative fac-
tors is in the movement analysis of physi-
cal demands. It is easy to understand
that tendons may become painful after
familiar activities (eg, running, pitching)
are performed in excess, overloading the
tendon (overuse). However, it is less clear
whether this scenario is strictly related to
tendon overload or whether degradation
in quality of motion may also be a caus-
ative factor. More perplexing is the ques-
tion of why tendons sometimes become
painful after familiar activities are per-
formed in familiar doses. Perhaps subop-
timal motion quality is partly to blame.
Tendinopathies are often placed in the
overuse category,5 but it may be just as
important to consider the causative fac-
tor of “wrong use.” How do we determine
wrong use? Movement strategies and
variability can provide insight into caus-
ative factors and may have broad appli-
cation to most, if not all, tendons that
develop tendinopathy.
The assessment of movement strate-
gies can provide insight as to why some
tendons develop a painful tendinopa-
thy. Movement should be analyzed at
the joints directly related to the tendi-
nopathy, and at the associated joints
and trunk. 22,29 Movement variability
can also provide insight to causation.
It has been well established that re-
petitive movements have variability.
In those with tendinopathy, movement
variability can be reduced, but it is un-
clear whether this is helpful or harm-
ful. With new computational methods,
we may be able to parcel out the “good”
from “bad” variability.32 Because dif-
ferent movement strategies have been
found in runners who have unilateral
Achilles tendinopathy,3 advanced analy-
sis techniques are needed to determine
those movement strategies which con-
tribute to the development or chronic-
ity of the tendinopathy. Interventions
should address the factors that contrib-
ute to faulty movement and wrong use,
which can be identified and addressed
during both pain remission of a chronic
tendinopathy13 as well as during pain-
ful episodes.3 Increased understanding
of movement variability and strate-
gies will advance our implementation
of treatment approaches that optimize
movement and reduce the development
of tendinopathy.
Should All Tendons Be
Managed the Same?
Management of a painful Achilles
should involve a multidimensional ap-
proach, as summarized in the EdUReP
(Educational interventions, periods of
tendon Unloading and controlled Re-
load, and implementation of Prevention
strategies).8 These ingredients remain
constant, but in varying amounts,
throughout the rehabilitative period.
Education includes discussion on the
management strategies of the underlying
pathology and the need for specific exer-
cises, especially during pain remission.
Unloading is accomplished by modifica-
tion of the type and volume of activity,
for example, in the Achilles, the use of
a heel lift as needed. Reloading is ten-
don, activity, and movement impair-
ment specific, with the use of slow and
progressively more demanding activities.
Reloading could include the assessment
and treatment of associated joints and
muscles, and the incorporation of power,
strength, and endurance. Prevention of
symptom recurrence, perhaps the most
challenging and somewhat speculative
10/21/2015 4:47:21 PM
 aspect of the management, relies on ef-
fective communication with the patients
and the implementation of mutually
agreed strategies.
Degenerated tendons lose their me-
chanical properties,4 and resistive exer-
Downloaded from www.jospt.org at Central Michigan University on November 1, 2015. For personal use only. No other uses without permission.
cises increase tendon stiffness,25 hence
the rationale for an appropriate dose of
resistive exercises.17 Eccentric exercises
performed slowly and through the full
range of motion (eg, maximal tendon
excursion) are commonly used for the
tendons of the lower extremities. The
rationale for eccentrics for degenerated
tendons is the need for tendon strain
exceeding habitual use,2 ability to toler-
ate progressively higher load in the later
stages of intervention, and preferentially
targeting the tendon as opposed to the
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
muscle. Exercise programs specifically for
Achilles tendinopathy have advocated the
use of high-volume daily eccentric exer-
cise for a period of 3 months. The large
volume of evidence supports this use of
eccentrics. However, the effect may not
be specific to eccentrics, as other forms
of loaded resistive exercise have shown
positive clinical outcomes and changes
Journal of Orthopaedic & Sports Physical Therapy®
in Achilles tendon pathology.21 For the
supraspinatus, the application of eccen-
trics is less well studied, and is not always
applied using the described specified pa-
rameters. The article by Couppé et al7 in
this special issue provides a critical re-
view of eccentric and concentric exercise
for tendinopathy.
For supraspinatus tendinopathy,
the EdUReP approach provides a ba-
sic framework to guide treatment. The
shoulder symptom modification pro-
cedure, described in this special issue,15
incorporates the principles of the previ-
ously described EdUReP approach of
education, relative rest, controlled re-
loading, exercise, and prevention strate-
gies. The shoulder symptom modification
procedure has promise to guide exercise
prescription by assessing the influence
of posture of the shoulder and spine on
patient symptoms. We hope to see fu-
ture studies that determine whether this
theoretical model has clinical utility and
journal of orthopaedic & sports physical therapy | volume 45 | number 11 | november 2015 |
45-11 Editorial5-Michener.indd 831
positive outcomes. Scapular symptom
alteration tests may guide treatment,
as these tests have been shown to de-
crease pain and increase the subacromial
space.12,27 The effects of eccentric exercise
in patients with rotator cuff tendinopa-
thy are less investigated than those in
the lower extremity. There is only 1 com-
parative clinical trial on eccentrics, and
it showed no superiority in patient-rated
outcomes when eccentrics were added
to a traditional exercise approach in pa-
tients with subacromial pain syndrome.19
The umbrella term tendinopathy cov-
ers all painful tendons. In reality, some
painful tendons may clearly be degener-
ated on imaging, and these changes may
correlate with the findings on the physi-
cal exam, whereas other tendinopathies
may lack any pathological correlates. We
purport that management of tendinopa-
thies needs to incorporate underlying
pathology26 and mechanisms of the ten-
dinopathy to include movement analysis
of the physical tasks and demands, such
as those described in this special issue
for patellar tendinopathy.22,29 A unique
characteristic of tendinopathies is their
episodic occurrence, which led to the
proposed continuum model: from a re-
active stage with likely inflammation to
a degenerative stage.6 This special issue
addresses 5 common tendinopathies, and
each has incorporated the unique func-
tional and regional demands, further sup-
porting the current notion that, because
all tendons are not created for equal use,
they need to be managed uniquely. t
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