The interface of mechanical loading and biological variables as they pertain to the development of tendinosis

Different tendons are designed to withstand different mechanical loads in their individual environments. Variable physiologic loading ranges and correspondingly different injury thresholds lead to tendon heterogeneity. Also, tendon heterogeneity is evident when examining how different tendons regulate their response to changes in mechanical loading (over- and under-loading). The response of tendons to changes in mechanical loading plays an important role in the induction and progression of tendinosis which is tendon degeneration without inflammation. Tendon overuse injury is likely related to abnormal mechanical loading that deviates from normal mechanical loading in magnitude, frequency, duration and/or direction. Mechanical loading that results in tendon overuse injury can initiate a repair process but, after failed initial repair, non-resolving chronic attempted repair appears to lead to a "smoldering" fibrogenesis. Contributions of regulatory components, including minor components in the "nerve-mast cell-myofibroblast axis", are key features in the development and progression of tendinosis. Hormonal and genetic factors may also influence risk for tendinosis. Further understanding of how tendinosis induction is related to mechanical use/overuse, how tendinosis progression is related to abnormal regulation of attempted repair, and how induction and/or progression are modulated by other risk factors may lead to interventions that mitigate risk and enhance functional repair.