Sports Medicine

, Volume 27, Issue 6, pp 393–408 | Cite as

Histopathology of Common Tendinopathies

Update and Implications for Clinical Management
  • Karim M. Khan
  • Jill L. Cook
  • Fiona Bonar
  • Peter Harcourt
  • Mats Åstrom
Injury Clinic


Tendon disorders are a major problem for participants in competitive and recreational sports. To try to determine whether the histopathology underlying these conditions explains why they often prove recalcitrant to treatment, we reviewed studies of the histopathology of sports-related, symptomatic Achilles, patellar, extensor carpi radialis brevis and rotator cuff tendons.

The literature indicates that healthy tendons appear glistening white to the naked eye and microscopy reveals a hierarchical arrangement of tightly packed, parallel bundles of collagen fibres that have a characteristic reflectivity under polarised light. Stainable ground substance (extracellular matrix) is absent and vasculature is inconspicuous. Tenocytes are generally inconspicuous and fibroblasts and myofibroblasts absent.

In stark contrast, symptomatic tendons in athletes appear grey and amorphous to the naked eye and microscopy reveals discontinuous and disorganised collagen fibres that lack reflectivity under polarised light. This is associated with an increase in the amount of mucoid ground substance,which is confirmedwithAlcian blue stain. At sites of maximal mucoid change, tenocytes, when present, are plump and chondroid in appearance (exaggerated fibrocartilaginous metaplasia). These changes are accompanied by the increasingly conspicuous presence of cells within the tendon tissue, most of which have a fibroblastic or myofibroblastic appearance (smooth muscle actin is demonstrated using an avidin biotin technique). Maximal cellular proliferation is accompanied by prominent capillary proliferation and a tendency for discontinuity of collagen fibres in this area.Often, there is an abrupt discontinuity of both vascular and myofibroblastic proliferation immediately adjacent to the area of greatest abnormality. The most significant feature is the absence of inflammatory cells.

These observations confirmthat the histopathological findings in athletes with overuse tendinopathies are consistent with those in tendinosis — a degenerative condition of unknown aetiology. This may have implications for the prognosis and timing of a return to sport after experiencing tendon symptoms.

As the common overuse tendon conditions are rarely, if ever, caused by ‘tendinitis’, we suggest the term ‘tendinopathy’ be used to describe the common overuse tendon conditions.We conclude that effective treatment of athletes with tendinopathiesmust target the most common underlying histopathology, tendinosis, a noninflammatory condition.


Adis International Limited Rotator Cuff Patellar Tendon Achilles Tendon Tendinitis 
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Copyright information

© Adis International Limited 1999

Authors and Affiliations

  • Karim M. Khan
    • 1
  • Jill L. Cook
    • 2
  • Fiona Bonar
    • 3
  • Peter Harcourt
    • 2
  • Mats Åstrom
    • 4
  1. 1.School of Human KineticsUniversity of British ColumbiaVancouverCanada
  2. 2.Tendon Study GroupVictorian Institute of SportMelbourneAustralia
  3. 3.Douglass Hanly Moir PathologySydneyAustralia
  4. 4.Department of OrthopaedicsLund UniversityMalmoSweden

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