Article Text

Download PDFPDF

Why do tendon researchers overlook the patient’s psychological state? The review with no papers
  1. Seán Mc Auliffe1,
  2. Kieran O'Sullivan2,3,
  3. Rod Whiteley4,5,
  4. Vasileios Korakakis4
  1. 1 Department of Physical Therapy and Rehabilitation Science, Qatar University, Doha, Qatar
  2. 2 School of Allied Health, University of Limerick, Limerick, Ireland
  3. 3 Health Research Institute, University of Limerick, Limerick, Ireland
  4. 4 Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  5. 5 University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Seán Mc Auliffe, Department of Physical Therapy & Rehabilitation Science, Qatar University, Doha, Qatar; macca{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Exercise or loading interventions remain the conservative treatment of choice in the management of tendinopathy.1 However, as many as 60% of individuals experience continued symptoms, while up to a quarter of patients experiencing symptoms 10 years after treatment.2

What might explain these rather sobering outcomes? We opine that given the complex and often persistent nature of tendinopathy, addressing other factors in addition to exercise variables may prove beneficial. We focus here on the potential role of psychological factors.

Psychological factors have been implicated in many other musculoskeletal disorders, either as prognostic factors,3 as treatment effect modifiers4 or as mediators of recovery.5 As tendinopathy has been shown to be associated with psychological distress and poor quality of life,6 7 measuring psychological factors in randomised controlled trials (RCTs) of exercise would appear justifiable. This does not mean outcomes will necessarily improve, but the evidence from other musculoskeletal disorders suggests that there is merit to understanding the potential implications of psychological factors on prognosis, treatment effect modification and mediation of pain in tendinopathy.

What has been done so far?

While conducting a systematic review and meta-analysis (CRD42018110086;, and in accordance with the recommendations of the recent International Scientific Tendinopathy Symposium, we sought to document the measurement of psychological factors in exercise-based interventions of tendinopathy.8

Specifically, we asked how many of the eligible exercise trials measured psychological factors as a baseline measure and follow-up. We found 45 RCTs that examined the role of exercise in either upper or lower limb tendinopathy; only two of these RCTs reported explicitly measuring psychological factors at baseline and at follow-up (Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and emotional distress using the Hopkins Symptom Checklist).9 10 This suggests that researchers in tendinopathy may not value psychological factors in exercise trials, we however do not agree.

Why, what, who, how: four recommendations to bridge the gap

  1. WHY do we need this? Evidence from musculoskeletal conditions such as low back pain and ACL injury suggests that psychological factors play a role in determining intervention outcomes in RCTs. Exercise interventions in tendinopathy require time and commitment from both the therapist and the patient. Considering the length of time often required to achieve desired outcomes with exercise interventions, we propose that psychological factors such as self-efficacy, fear avoidance beliefs, treatment expectations etc. are important factors to consider alongside biological factors (reps, sets, frequency and so on) when designing and delivering exercise interventions in tendinopathy. It is time for researchers to ask about psychological factors in exercise RCTs.

  2. WHAT psychological factors are most relevant? Data from observational studies suggest factors including fear and self-efficacy are relevant for tendinopathy.6 However, the number of studies remains small, and it is important to consider whether we currently have the tools to appropriately capture these important factors in people with tendon pain and whether the same tools could be used across different tendons.

  3. WHO are these factors most relevant for? Appropriate screening, identification and subgrouping of individuals with relevant psychological factors may be warranted in tendinopathy. If clinicians are able to identify patients with modifiable psychological factors, rehabilitation could be suitably adjusted by providing appropriate education, coaching or motivational strategies.

  4. HOW? Consider how better psychological profiling of people with tendinopathy could inform the exercise programmes we deliver. For example, can we maximise any positive effect on relevant psychological factors (eg, reduce fears or anxieties about the person being damaged or vulnerable) when prescribing, delivering and evaluating the response to exercise, rather than making people feel more vulnerable (figure 1)?

Figure 1

Why, what, who, how: four recommendations to address this gap. MSK, musculoskeletal; RCTs, randomised controlled trials.

Tendinopathy is difficult—both for the individual and for the treating clinician. Exercise is the cornerstone of treatment in tendinopathy. To improve clinical outcomes with exercise interventions in tendinopathy, tendinopathy researchers should stop playing lip-service to a biopsychosocial rehabilitation approach. Integrating psychological outcomes within exercise paradigms and interventions will improve patient outcomes.



  • Twitter @Seaniemc89, @kieranosull, @RodWhiteley

  • Contributors All authors provided equal contribution to the composition of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.