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Review
, 50 (19), 1187-91

Revisiting the Continuum Model of Tendon Pathology: What Is Its Merit in Clinical Practice and Research?

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Review

Revisiting the Continuum Model of Tendon Pathology: What Is Its Merit in Clinical Practice and Research?

J L Cook et al. Br J Sports Med.

Abstract

The pathogenesis of tendinopathy and the primary biological change in the tendon that precipitates pathology have generated several pathoaetiological models in the literature. The continuum model of tendon pathology, proposed in 2009, synthesised clinical and laboratory-based research to guide treatment choices for the clinical presentations of tendinopathy. While the continuum has been cited extensively in the literature, its clinical utility has yet to be fully elucidated. The continuum model proposed a model for staging tendinopathy based on the changes and distribution of disorganisation within the tendon. However, classifying tendinopathy based on structure in what is primarily a pain condition has been challenged. The interplay between structure, pain and function is not yet fully understood, which has partly contributed to the complex clinical picture of tendinopathy. Here we revisit and assess the merit of the continuum model in the context of new evidence. We (1) summarise new evidence in tendinopathy research in the context of the continuum, (2) discuss tendon pain and the relevance of a model based on structure and (3) describe relevant clinical elements (pain, function and structure) to begin to build a better understanding of the condition. Our goal is that the continuum model may help guide targeted treatments and improved patient outcomes.

Keywords: Tendon.

Figures

Figure 1
Figure 1
What is inflammation? Courtesy Dr James Gaida.
Figure 2
Figure 2
Schematic representation of ‘reactive-on-degenerative’ tendinopathy. A representation an example of the presentation on (ultrasound tissue characterisation is presented by Rudavsky and Cook.
Figure 3
Figure 3
Relationship between structure, function and pain. The relative sizes of the boxes may vary from tendon to tendon.
Figure 4
Figure 4
Schematic representation of how we may phenotype patients with tendinopathy in relation to the continuum and target treatments. The aim of treatment is to push the tendon into the green section with relatively little pain and good function. Tendon structure can be normalised in the early stages of the continuum where rehabilitation can push the tendon ‘up the continuum’. In the latter stages of the continuum, ‘moving up the continuum’ may not be possible, so interventions should be focused in ‘moving the tendon sideways’. It is important to note that interventions directed solely at pain will not drive the tendon to a positive outcome as they do not address dysfunction, such as motor inhibition, strength and power deficits, or tendon load capacity. Interventions that target structure may improve tendon structure and direct the tendon ‘upwards along the continuum’; however, it will not address functional deficits (effect on pain is inconclusive) or load capacity and may leave the tendon vulnerable to reinjury.

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