There has been recent discussion in the journal regarding the pathophysiological mechanisms of the development of tendinopathy.1 2 To date there has been no discussion on the role of the enveloping fascia in this condition. In other related musculotendinous conditions, there is evidence that inflammation of the fascia occurs, for example, in plantar fasciitis.3 Histological examination of this condition demonstrates a reactive-type inflammatory infiltrate with accompanying proteoglycan production and oedema seen with collagen thickening. The process is well demonstrated more diffusely in eosinophillic fasciitis, a rare scleroderma-type condition first described in 1974 by Shulman,4 which has a wide and varied clinical presentation.

Cook and Purdam1 propose a model of tendinopathy beginning with reactive change, although with no inflammatory component, which in turn leads on to tendon disrepair and ultimately tendon degeneration. What may well be missing is the “progenitor” stage, and by ignoring the potential role of the fascia and the fascia–tendon interface, we are potentially missing a critical aspect of this condition.

The gross fascial anatomy of the lower limb is poorly documented, …