Sports Medicine

, Volume 46, Issue 4, pp 545–557 | Cite as

At What Age Do Children and Adolescents Develop Lower Limb Tendon Pathology or Tendinopathy? A Systematic Review and Meta-analysis

  • Mitchell Simpson
  • Ebonie Rio
  • Jill Cook
Systematic Review



Tendon pathology and tendinopathy have been reported in children and adolescents; however, the age at onset and prevalence of the conditions have not been examined systematically.


To examine the prevalence of lower limb tendon pathology and tendinopathy in children and adolescents, and the factors associated with these conditions in this population.


Six databases were searched (MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Scopus, the Web of Science and the Allied and Complementary Medicine Database). Studies were included if the prevalence of lower limb tendon pathology and/or tendinopathy were reported in humans under the age of 18 years. Studies were divided according to the method of diagnosis (physical examination, ultrasound or a questionnaire) and further divided into studies that reported prevalence data by tendon [reported two data points (right and left) for each participant] and those that reported prevalence data for each participant [reporting one data point (right or left) per participant].


Seventeen studies met the inclusion criteria. Lower limb tendinopathy prevalence (presence of pain and dysfunction) ranged between 8.2 and 33.3 %, and increased in prevalence as age increased up to 18 years. The odds ratio for studies reporting tendinopathy by tendon was 0.37 (95 % confidence interval 0.20–0.69) in favour of boys presenting with tendinopathy. Study aims and reporting methods were heterogeneous.


The age at onset of lower limb tendinopathy in children and adolescents has not been widely studied. This systematic review found that tendinopathy is present in children and adolescents, and increases in prevalence with age up to 18 years. Male sex is significantly associated with tendinopathy in studies that report tendinopathy by tendon.


Patellar Tendon Tendon Injury Basketball Player American Football Achilles Tendinopathy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Mitchell Simpson designed the review, completed the literature search, designed and completed the quality assessment of all studies, drafted the initial manuscript, and approved the final manuscript as submitted. Ebonie Rio assisted with the design of the review and search terms, reviewed and revised the manuscript, and approved the final manuscript as submitted. Jill Cook assisted with the design of the review and search terms, assessed the quality of the studies, supervised the initial draft of the manuscript, critically reviewed the manuscript, and approved the final manuscript as submitted. All authors agree to be accountable for all aspects of the work.

Compliance with Ethical Standards


Jill Cook is supported by the Australian Centre for Research into Sports Injury and Its Prevention, which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). Jill Cook is also a National Health and Medical Research Council practitioner fellow (ID 1058493). All funding for this systematic review was provided in kind by Monash University. No external funding was secured for this review.

Conflicts of interest

Mitchell Simpson, Ebonie Rio and Jill Cook declare that they have no conflicts of interest relevant to the content of this review.

Supplementary material

40279_2015_438_MOESM1_ESM.docx (73 kb)
Supplementary material 1 (DOCX 73 kb)
40279_2015_438_MOESM2_ESM.docx (64 kb)
Supplementary material 2 (DOCX 64 kb)
40279_2015_438_MOESM3_ESM.docx (106 kb)
Supplementary material 3 (DOCX 105 kb)


  1. 1.
    Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409–16.CrossRefPubMedGoogle Scholar
  2. 2.
    Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports. 2008;18(1):3–15.CrossRefPubMedGoogle Scholar
  3. 3.
    Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). J Physiother. 2014;60(3):122–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87(1):187–202.CrossRefPubMedGoogle Scholar
  5. 5.
    Khan KM, Cook JL, Kannus P, et al. Time to abandon the “tendinitis” myth. BMJ. 2002;324(7338):626–7.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Magnusson SP, Langberg H, Kjaer M. The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 2010;6(5):262–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003;22(4):675–92.CrossRefPubMedGoogle Scholar
  8. 8.
    Riley G. The pathogenesis of tendinopathy: a molecular perspective. Rheumatology (Oxford). 2004;43(2):131–42.CrossRefPubMedGoogle Scholar
  9. 9.
    Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med. 2013;47(9):536–44.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Adler RS, Finzel KC. The complementary roles of MR imaging and ultrasound of tendons. Radiol Clin North Am. 2005;43(4):771–807, ix.Google Scholar
  11. 11.
    Cook JL, Khan KM, Harcourt PR, et al. A cross sectional study of 100 athletes with jumper’s knee managed conservatively and surgically. The Victorian Institute of Sport Tendon Study Group. Br J Sports Med. 1997;31(4):332–6.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Cook JL, Kiss ZS, Khan KM, et al. Anthropometry, physical performance, and ultrasound patellar tendon abnormality in elite junior basketball players: a cross-sectional study. Br J Sports Med. 2004;38(2):206–9.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Bahr MA, Bahr R. Jump frequency may contribute to risk of jumper’s knee: a study of interindividual and sex differences in a total of 11 943 jumps video recorded during training and matches in young elite volleyball players. Br J Sports Med. 2014;48(17):1322–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Rosengarten SD, Cook JL, Bryant AL, et al. Australian football players’ Achilles tendons respond to game loads within 2 days: an ultrasound tissue characterisation (UTC) study. Br J Sports Med. 2015;49(3):183–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Warden SJ, Brukner P. Patellar tendinopathy. Clin Sports Med. 2003;22(4):743–59.CrossRefPubMedGoogle Scholar
  16. 16.
    La Maurizio E. tendinite rotulea del giocatore di pallavolo. Arch Soc Tosco Umbra Chir. 1963;24:443–7.Google Scholar
  17. 17.
    Blazina ME, Kerlan RK, Jobe FW, et al. Jumper’s knee. Orthop Clin North Am. 1973;4(3):665–78.PubMedGoogle Scholar
  18. 18.
    Ferretti A, Puddu G, Mariani PP, et al. Jumper’s knee: an epidemiological study of volleyball players. Physician Sportsmed. 1984;12(10):97–106.Google Scholar
  19. 19.
    Gisslen K, Gyulai C, Soderman K, et al. High prevalence of jumper’s knee and sonographic changes in Swedish elite junior volleyball players compared to matched controls. Br J Sports Med. 2005;39(5):298–301.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Visnes H, Bahr R. Training volume and body composition as risk factors for developing jumper’s knee among young elite volleyball players. Scand J Med Sci Sports. 2013;23(5):607–13.PubMedGoogle Scholar
  21. 21.
    Benjamin M, Toumi H, Ralphs JR, et al. Where tendons and ligaments meet bone: attachment sites (‘entheses’) in relation to exercise and/or mechanical load. J Anat. 2006;208(4):471–90.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    McGonagle D, Benjamin M. Muscle attachments to bone as an unrecognised cause of pain 2013 (cited 2014). 2013.
  23. 23.
    Barber Foss KD, Myer GD, Chen SS, et al. Expected prevalence from the differential diagnosis of anterior knee pain in adolescent female athletes during preparticipation screening. J Athlet Train. 2012;47(5):519–24.Google Scholar
  24. 24.
    Kardouni JR, Seitz AL, Walsworth MK, et al. Neovascularization prevalence in the supraspinatus of patients with rotator cuff tendinopathy. Clin J Sport Med. 2013;23(6):444–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Littlewood C, May S, Walters S. Epidemiology of rotator cuff tendinopathy: a systematic review. Shoulder Elbow. 2013;5(4):256–65.Google Scholar
  26. 26.
    Stasinopoulos D, Stasinopoulos I, Pantelis M, et al. Comparison of effects of a home exercise programme and a supervised exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med. 2010;44(8):579–83.CrossRefPubMedGoogle Scholar
  27. 27.
    Stasinopoulos D, Stasinopoulou K, Johnson MI. An exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med. 2005;39(12):944–7.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Cassel M, Baur H, Hirschmuller A, et al. Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes. Scand J Med Sci Sports. 2015;25(3):e310–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Le Gall F, Carling C, Reilly T. Biological maturity and injury in elite youth football. Scand J Med Sci Sports. 2007;17(5):564–72.PubMedGoogle Scholar
  30. 30.
    Steinberg N, Siev-Ner I, Peleg S, et al. Injury patterns in young, non-professional dancers. J Sports Sci. 2011;29(1):47–54.CrossRefPubMedGoogle Scholar
  31. 31.
    Visnes H, Tegnander A, Bahr R. Ultrasound characteristics of the patellar and quadriceps tendons among young elite athletes. Scand J Med Sci Sports. 2014;25(2):205–15.CrossRefPubMedGoogle Scholar
  32. 32.
    Cook JL, Khan KM, Kiss ZS, et al. Patellar tendinopathy in junior basketball players: a controlled clinical and ultrasonographic study of 268 patellar tendons in players aged 14–18 years. Scand J Med Sci Sports. 2000;10(4):216–20.CrossRefPubMedGoogle Scholar
  33. 33.
    Gisslen K, Alfredson H. Neovascularisation and pain in jumper’s knee: a prospective clinical and sonographic study in elite junior volleyball players. Br J Sports Med. 2005;39(7):423–8.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Gluckman P, Low F, Franko K. Puberty and adolescence: transitions in the life course. Auckland: Office of the Prime Minister’s Science Advisory Committee; 2011.Google Scholar
  35. 35.
    Blakemore SJ, Burnett S, Dahl RE. The role of puberty in the developing adolescent brain. Hum Brain Mapp. 2010;31(6):926–33.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Johnson A, Doherty PJ, Freemont A. Investigation of growth, development, and factors associated with injury in elite schoolboy footballers: prospective study. BMJ. 2009;338:b490.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Gastin PB, Bennett G, Cook J. Biological maturity influences running performance in junior Australian football. J Sci Med Sport. 2013;16(2):140–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Public Health Resource Unit. Critical Appraisal Skills Programme [CASP]: making sense of evidence. Oxford. 2006. Accessed 12 Sept 2014.
  39. 39.
    Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun Health. 1998;52(6):377–84.CrossRefGoogle Scholar
  40. 40.
    de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2):129–33.CrossRefPubMedGoogle Scholar
  41. 41.
    Menz HB. Two feet, or one person? Problems associated with statistical analysis of paired data in foot and ankle medicine. Foot. 2003;14(1):2–5.CrossRefGoogle Scholar
  42. 42.
    Backman LJ, Danielson P. Low range of ankle dorsiflexion predisposes for patellar tendinopathy in junior elite basketball players: a 1-year prospective study. Am J Sports Med. 2011;39(12):2626–33.CrossRefPubMedGoogle Scholar
  43. 43.
    Bergstrom KA, Brandseth K, Fretheim S, et al. Activity-related knee injuries and pain in athletic adolescents. Knee Surg Sports Traumatol Arthrosc. 2001;9(3):146–50.CrossRefPubMedGoogle Scholar
  44. 44.
    Cook JL, Khan KM, Kiss ZS, et al. Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J Ultrasound Med. 2000;19(7):473–9.PubMedGoogle Scholar
  45. 45.
    Cook JL, Khan KM, Kiss ZS, et al. Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Victorian Institute of Sport Tendon Study Group. Br J Sports Med. 2001;35(1):65–9.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Dubravcic-Simunjak S, Pecina M, Kuipers H, et al. The incidence of injuries in elite junior figure skaters. Am J Sports Med. 2003;31(4):511–7.PubMedGoogle Scholar
  47. 47.
    Galanty HL, Matthews C, Hergenroeder AC. Anterior knee pain in adolescents. Clin J Sports Med. 1994;4(3):176–81.CrossRefGoogle Scholar
  48. 48.
    Gisslén K, Gyulai C, Nordström P, et al. Normal clinical and ultrasound findings indicate a low risk to sustain jumper’s knee patellar tendinopathy: a longitudinal study on Swedish elite junior volleyball players. Br J Sports Med. 2007;41(4):253–8.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Kish RL, Plastino JG, Martyn-Stevens B. A young dancer survey. Med Probl Perform Art. 2003;18(4):161–5.Google Scholar
  50. 50.
    Toprak U, Üstüner E, Uyanik S, et al. Comparison of ultrasonographic patellar tendon evaluation methods in elite junior female volleyball players: thickness versus cross-sectional area. Diagn Intervention Radiol. 2012;18(2):200–7.Google Scholar
  51. 51.
    Cook JL, Khan KM, Harcourt PR, et al. Patellar tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian Institute of Sport Tendon Study Group. Clin J Sports Med. 1998;8(2):73–7.CrossRefGoogle Scholar
  52. 52.
    Ferretti A. Epidemiology of jumper’s knee. Sports Med. 1986;3(4):289–95.CrossRefPubMedGoogle Scholar
  53. 53.
    Lian O, Holen KJ, Engebretsen L, et al. Relationship between symptoms of jumper’s knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Sci Sports. 1996;6(5):291–6.CrossRefPubMedGoogle Scholar
  54. 54.
    Nicolini AP, de Carvalho RT, Matsuda MM, et al. Common injuries in athletes’ knee: experience of a specialized center. Acta Ortop Bras. 2014;22:127–31.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Department of PhysiotherapyMonash University PeninsulaMelbourneAustralia

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