In search of the tendon holy grail: predictable clinical outcomes

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Abstract
Tendon is incredibly complex tissue that refuses to behave in any sort of structured reparative way or respond to clinical interventions with consistent outcomes. We are very familiar with the conundrums that tendinopathy presents. Place load on an already sore tendon and it often becomes more painful, but resting it does not offer any long-term relief. Exercising tendons eccentrically seems to improve them; concentric exercise of identical load does not have the same effect! How many clinical explanations are there for why eccentric exercise is effective? I have heard many, including the effect of stretching when loaded, the range of movement that the tendon goes through, and even that eccentric exercises stimulate healing. A review in this issue1 (see page 242) might help you explain to your patient why eccentric movements are better than concentric. You’ll appreciate the paper that asks what aspects of the standard eccentric exercise programme have the most effect—I suspect you might be surprised by the answers2 (see page 276).