New insights into tendon pain

Tendon pain is often referred to as tendinopathy (previously referred to as tendinitis or tendinosis) and can affect different areas in the body. A few common areas include the Achilles tendon, the Gluteal tendon and Tennis Elbow.

Tendon pain is known to be quite stubborn in its recovery. You can’t rest it better. You can easily piss it off by doing too much. Many treatments may work in the short term (e.g., injections) but have little impact on pain in the long-term.

There is a shift in the way we have always viewed tendon pain. Previously we viewed it as a load management issue and mainly mechanical. Now there is some emergent evidence to show a link between metabolic health (body weight, cholesterol & blood sugar levels) and tendon pain.

A systematic review (analysed all available studies in the area) looked at this link closer to find out more.

It found a total of 53 studies that met the inclusion criteria.

What did they find:

• Tendon pain in the lower limbs is more frequently seen in people with diabetes vs people without diabetes. Across the included studies, Achilles tendinopathy prevalence in people with diabetes reached up to 67%, and diabetes was associated with about 7 times higher odds of Achilles tendinopathy compared with people without diabetes. There are several theories (not solid science) on how this may occur however, it seems like diabetes can negatively impact the health of a tendon through different possible mechanisms.
  

• Some studies in the review suggested tendinopathy was seen in people with hypercholesterolaemia and in statin users, but the findings were inconsistent and the authors considered the statin evidence inconclusive.  
  

• Tendon pain was also higher in people with higher BMI’s. However, there was no data on body composition.

It is always good to highlight a view limitations with the study to ensure it is analysed with some caution:

• A tendinopathy diagnosis is not straight forward and imaging is not always useful in making the diagnosis. Sometimes scans show a ‘tendinopathy’ that is not actually symptomatic and is considered an incidental finding. Some included studies diagnosed tendinopathy using imaging.
  

• All types of studies were included - some of lower quality.
  

• The risk of bias assessment completed by the authors revealed significant variation in the quality of the studies.

The take-away, and conclusions 

• Pain is always complex and the experience is influenced by different factors - physiological, psychological and social. 
  

• Another factor that we now need to consider in the pain experience are metabolic factors - diabetes, high cholesterol and body weight (or composition).  
  

• These factors may not directly cause tendon pain however, they do seem to be playing a role.
  

• If you are seeking care for tendon pain, it may be worth also looking at improving your metabolic health in the long-term.   

So overall, this doesn’t mean tendon pain is caused by cholesterol or blood sugar alone. It means recovery may be influenced by more than just load and exercise. 

If you have stubborn tendon pain, it may be worth thinking beyond the tendon itself and considering broader factors like training load, sleep, stress, and metabolic health. 

Written by

Samuel Bulten

Exercise Physiologist | Masters in Medicine (Pain Management)

Director, Adapt Movement

Disclaimer

This information is for educational purposes only and is not a substitute for personal medical advice. These blogs are written by Sam Bulten and represent his opinions and insights and are based on his experience and interpretation of the research. As Sam is a human, these opinions and insights are not absolute truths.