Was an action packed and interesting 2 days in Oxford at the 3rd International Scientific Tendinopathy Symposium 2014. As one of my students commented, ‘this must be like Mecca for the tendophiles’. It is indeed very indulgent to talk tendons uninterrupted
The conference was divided into a basic science day and clinical translation day. I must say it did feel a little more basic science, but this was balanced out by some clinical workshops on day three. What was apparent is the huge difference in the languages that basic science and clinical researchers speak. Quite often a basic science researcher would launch into their life’s work on specific biochemical (e.g. MMP’s) without a huge amount of basic background eg what are these substances, what do they do. Of course this is all assumed knowledge for those in the know.


When you put the basic science language aside, what is clear is that the basic scientists, as you would expect, are very focused on the biochemical processors involved in the tendon adaptation, regulation, homeostasis and pathology. One of their key challenges is finding models that relate to human overuse tendinopathy. On the other hand, clinicians speak more about managing pain, and cannot agree on the importance of pathology on imaging or how this information can be used. Some feel pathology is never relevant, largely because it is not clearly correlated with pain and does not seem to change with imaging. Others feel it is always relevant. I feel, the answer is in the middle but there is only clinical experience to guide us at this stage.


I talk about how to use imaging, when it is important, and how to clinically assess and rehab tendons individually in my courses. Am about to deliver three in the uk, and some dates coming up in Melbourne and Sydney in November…see details here
Here is a summary of interesting new research and some clinical take home messages from the conference. You can also access the abstracts here.


Interesting new material
There was lots on the use of UTC, which is ultrasound tissue characterisation. It uses post processing on conventional gray scale ultrasound to assess the matrix structure, from well aligned to amorphous. There was some potential clinical uses in confirming a plantaris component presented by Lorenzo Masci et. al. You can clearly see changes localised to the plantaris and adjoining medial tendon that were less clear with gray scale. Sean Docking et al. showed more aligned matrix in the pathological vs normal patellar tendons, indicating that the increased metabolism of pathological tendons may lead to adaptation, or it may be explained by fibril thickening, which has been reported in pathology (Kongsgaard et al. 2010). The interesting part of this study is that the greater aligned matrix was on the periphery, around the characteristic cyclops lesion at the inferior pole, which supports previous data that perhaps the degenerate area of tendon does not adapt (Malliaras et al. 2010), but the periphery may. A study following young volleyball players daily over a 5-day tournament did not show short term changes in UTC, in contrast to a recent study by Rostegarten et al. (2014) in Australian Rules Football. So more work needs to be done to understand how to use UTC in monitoring athletes load for prevention, but there may be some useful applications in diagnosis, particularly for plantaris. Not sure if that justifies the 50grand expenditure??


Kongsgaard M, Qvortrup K, Larsen J, et al.: Fibril morphology and tendon mechanical properties in patellar tendinopathy effects of heavy slow resistance training. The American Journal of Sports Medicine. 2010, 38:749-756.

Malliaras P, Purdam C, Maffulli N, Cook J: Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon. Br J Sports Med. 2010, 44:944-947.

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. British Journal of Sports Medicine. 2014:bjsports-2013-092713.

Seth O’Neill presented some of his PhD work that showed that there are strength deficits in Achilles patients, and that regular eccentrics do not reverse these deficits completely, although people do get stronger. Incomplete recovery of strength may indicate continued motor cortex inhibition. That leads me onto another excellent bit of researcher, relating to reduction in pain and motor cortex inhibition in patellar tendon following isometric loading, by Ebonie Rio et al. Won’t go into details as have discussed in detail on the blog. Suffice to say isometrics are great! Another interesting clinical study was by Allison Grimaldi et al., looked at accuracy of clinical testing for diagnosing lateral hip tendinopathy, showing that palpating as expected is very sensitive, also that standing on 1 leg for more than 30 sec will likely bring on pain in gluteal tendon patients. Only issue is they used imaging as gold standard and we know imaging positive people are not always painful, clinical assessment of lateral hip tendinopathy based on clinical features may have been better.

There were great presentations by Jo Gibson and Andy Carr providing practical and clinical information for management as well as evidence relating to cental sensitisation for upper limb disorders. Andy showed evidence of fMRI in relation to shoulder surgery and neuropathic pain scores. Jo highlighted some excellent points for clinicians, including the importance of taking patients’ focus away from imaging ‘tears’ and the importance of language and positive sensory input in management and progressive rehabilitation.

Aside from this there was lots and lots of basic science research. The pick of the bunch for me was work by Hazel Screen’s group into the structure and function of the intrafasicular tendon matrix, ie the region between collagen fascicles. This seems to have a role in energy storage and they have also shown greater cell concentration, response to loading and matrix pathology changes in this region.


Malcolm Collins spoke wonderfully on applying the genetic associations in tendinopathy from his and other groups to the clinical context. He emphasised the point that genetic associations can never be predictive or diagnostic, but may increase risk. The future in this field may involve identifying responders and nonresponders to certain treatments, which would be very exciting.

Overall, a very worthwhile conference, albeit limited ideas to take back to the clinic. Interestingly, there were no podium talks on exercise interventions for tendinopathy (only posters) despite this being the most effective treatment for tendinopathy. Summarised well by Adam Meakins on twitter – we have a long way to go in understanding tendons and agreement between clinicians in rare.