Primary disorders of tendons are common and constitute a high proportion of referrals to rheumatologists. Certain tendons are particularly vulnerable to degenerative pathology; these include the Achilles, patella, elements of the rotator cuff, forearm extensors, biceps brachi and tibialis posterior tendons. Disorders of these tendons are often chronic and can be difficult to manage successfully in the long term. Significant advances have been made in understanding the pathophysiology of these conditions. Histopathological evidence, together with advances in imaging techniques, has made us more appreciative of the degenerative (rather that inflammatory) nature of these conditions. Additionally the presence of neovascularization is now well-recognized in long-standing tendinopathy. We review the mechanical, vascular and developing neural theories that attempt to explain the aetiology of degenerative tendinopathy. We also explore theories of why specific tendons (such as the Achilles and supraspinatus tendons) are particularly prone to degenerative pathology. Traditionally, treatments have placed a heavy emphasis on anti-inflammatory strategies, which are often inappropriate. Recently, however, significant advances in the practical management of tendon disorders have been made. In particular the advent of 'eccentric loading' training programmes has revolutionized the treatment of Achilles tendinopathy in some patients. This concept is currently being extended to include other commonly injured tendons. Other current treatments are reviewed, as are potential future treatments.

Overuse disorders of tendons, or tendinopathies, present a challenge to sports physicians, surgeons, and other health care professionals dealing with athletes. The Achilles, patellar, and supraspinatus tendons are particularly vulnerable to injury and often difficult to manage successfully. Inflammation was believed central to the pathologic process, but histopathologic evidence has confirmed the failed healing response nature of these conditions. Excessive or inappropriate loading of the musculotendinous unit is believed to be central to the disease process, although the exact mechanism by which this occurs remains uncertain. Additionally, the location of the lesion (for example, the midtendon or osteotendinous junction) has become increasingly recognized as influencing both the pathologic process and subsequent management. The mechanical, vascular, neural, and other theories that seek to explain the pathologic process are explored in this article. Recent developments in the nonoperative management of chronic tendon disorders are reviewed, as is the rationale for surgical intervention. Recent surgical advances, including minimally invasive tendon surgery, are reviewed. Potential future management strategies, such as stem cell therapy, growth factor treatment, and gene transfer, are also discussed.

It is currently widely accepted among clinicians that chronic tendinopathy is caused by a degenerative process devoid of inflammation. Current treatment strategies are focused on physical treatments, peritendinous or intratendinous injections of blood or blood products and interruption of painful stimuli. Results have been at best, moderately good and at worst a failure. The evidence for non-infammatory degenerative processes alone as the cause of tendinopathy is surprisingly weak. There is convincing evidence that the inflammatory response is a key component of chronic tendinopathy. Newer anti-inflammatory modalities may provide alternative potential opportunities in treating chronic tendinopathies and should be explored further.

In September 2010, the first International Scientific Tendinopathy Symposium (ISTS) was held in Umeå, Sweden, to establish a forum for original scientific and clinical insights in this growing field of clinical research and practice. The second ISTS was organised by the same group and held in Vancouver, Canada, in September 2012. This symposium was preceded by a round-table meeting in which the participants engaged in focused discussions, resulting in the following overview of tendinopathy clinical and research issues. This paper is a narrative review and summary developed during and after the second ISTS. The document is designed to highlight some key issues raised at ISTS 2012, and to integrate them into a shared conceptual framework. It should be considered an update and a signposting document rather than a comprehensive review. The document is developed for use by physiotherapists, physicians, athletic trainers, massage therapists and other health professionals as well as team coaches and strength/conditioning managers involved in care of sportspeople or workers with tendinopathy.