Sports Medicine

, Volume 34, Issue 14, pp 1005–1017 | Cite as

Biomechanics and Pathophysiology of Overuse Tendon Injuries

Ideas on Insertional Tendinopathy
  • Constantinos N. MaganarisEmail author
  • Marco V. Narici
  • Louis C. Almekinders
  • Nicola Maffulli
Review Article


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.


Patellar Tendon Achilles Tendon Contractile Force Overuse Injury Lateral Epicondylitis 
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.



No sources of funding were received to assist in the preparation of this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this manuscript.


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© Adis Data Information BV 2004

Authors and Affiliations

  • Constantinos N. Maganaris
    • 1
    Email author
  • Marco V. Narici
    • 1
  • Louis C. Almekinders
    • 2
  • Nicola Maffulli
    • 3
  1. 1.Institute for Biophysical and Clinical Research into Human MovementManchester Metropolitan UniversityAlsagerUK
  2. 2.North Carolina Orthopaedic ClinicDuke University Health SystemDurhamUSA
  3. 3.Department of Trauma and Orthopaedic SurgeryKeele University School of Medicine, North Staffordshire HospitalHartshill, Stoke-on-TrentUK

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