Over the next several weeks, this newsletter series will serve as your runway to the Traverse City Tendon Summit.

Each installment highlights key ideas across the Summit’s three major content areas:

1. Foundational Science

2. Evaluation and Diagnostics

3. Management and Decision Making

The goal is simple. We want everyone arriving in April with a shared platform of understanding so that the conversations can move quickly past the basics and into the deeper, more meaningful discussions that drive real progress. None of the ideas introduced here should be taken as settled science. These nuances invite debate and discussion, and that exchange is central to the purpose of the Summit.

In our last installment, we extensively covered an overarching framework to guide tendon management and decision making. In this newsletter, we will cover more specific applications of these concepts when applied to healthy tendons.

Context is king. Tendon function cannot be separated from the organism, environment, and task demands. Therefore, we must center this article around a specific example to give any meaning.

Jarred Boyd was an obvious choice to broach this topic at the Summit. He has done an incredible job throughout his career organizing a wealth of knowledge surrounding musculoskeletal health and adaptive capacities and leveraging that information at the highest level of sport. As such, we will use Jarred’s current environment, NBA basketball, as the backdrop for the framing of this topic.

Management & Decision Making: Part II

KEY TAKEAWAYS

• Context is key in decision-making. A generic load profile cannot replace a well‑constructed task analysis that clarifies how individual, task, and environmental constraints interact to create the system’s demands. Those emergent demands must then anchor any tissue‑specific considerations that follow.

• Prevention data often overlook key mediators that shape outcomes. Structural integrity appears to meaningfully influence how athletes respond to prophylactic loading. The “watershed effect” suggests that pooled analyses may mask opposite responses in athletes with different baseline tissue states.

• Most prevention studies do not apply loading protocols that reflect modern mechanobiological principles. Few interventions deliver progressive overload or target individualized strain profiles (4.5-6.5%) associated with tendon adaptation. As a result, many studies cannot meaningfully test whether targeted loading can influence risk.

• A structural threshold exists that alters the effectiveness of both direct and indirect prevention strategies. As disorganization accumulates, standardized loading is more likely to exceed internal strain limits. Movement‑based offloading strategies also lose effectiveness because they cannot reduce strain enough to matter.

Begin With The End In Mind

Understanding the Demands of the Modern Game

In the performance realm: "The only rule is, it has to work." At the end of the day, every practitioner is judged against a single metric: the degree to which their work contributes to success. In team sports, there are many degrees of freedom between a healthy Achilles tendon in an individual athlete and the win–loss record of a team. Still, a direct line should exist between each step to anchor decisions to that outcome. On‑court movement capabilities that increase the likelihood of success can be broken down into global neuromuscular competencies, which can be further subdivided into the tissue‑specific qualities required to express those outputs.

A thorough understanding of the physiological demands of the sport is foundational to moving the needle. At a high level, basketball is characterized by short, high‑intensity bouts of activity performed at medium to high frequencies [1]. Historical time–motion data from the early 2000s indicates players cover approximately 4500–5000 meters in a typical 48‑minute game, spending 34.1% of time playing, 56.8% walking, and 9.0% standing. That active time reflects a blend of multiplanar demands, with an average of 105 intense movements per game, or roughly one every 21 seconds. Typical movements associated with the sport include jumping, cutting, lateral and backward shuffling, and sprinting, each imposing distinct neuromuscular and mechanical requirements.

Interpret these numbers cautiously. Much of the composite data available in the literature is derived from youth or sub‑elite leagues rather than NBA athletes. Competition level meaningfully alters the internal and external load profile, and extrapolating youth data to professional contexts introduces error [2].

Not only this, but general data obscures the contextual importance of an athlete’s position and role within a coaching scheme. The emphasis was placed on “early 2000s” above to highlight that historical data were collected before the major schematic shifts that define the modern game. Greater spacing, higher‑tempo transitions, increased three‑point frequency, and rapid defensive shifts have expanded the physical “footprint” required of each position. Players with different roles on the court experience very different movement and loading demands, even if they’re listed at the same position [3].

And even this is not the complete picture of load. Over 80% of the time on the court is spent in non‑game activities [4]. This means that practice design and philosophy of the coaching staff represents a major, largely unquantified determinant of the athlete’s true physiological exposure. Two teams can play the same sport under the same rules and produce fundamentally different load environments.

This is the landscape clinicians like Jarred must navigate. He has to speak both performance and physiology fluently. His work starts with translating the realities of the sport into tissue‑specific requirements, and that process cannot be outsourced to league averages or historical load profiles. Jarred (and practitioners in similar roles) must develop a granular understanding of the athlete and the environment they operate in. Only then can those demands be translated into training that produces the adaptations the sport requires, while still accounting for the realities of time, schedule, and player preferences.

Why Context Determines the Quality of Decisions

The intent of this newsletter is not to turn every reader into a subject matter expert in NBA player demands. The purpose is to illustrate how the reasoning principles discussed in previous newsletters only function as intended when they are anchored to the physiological reality of the individual in front of you. 

In most other settings, this level of detail may not always be required, but the underlying principle remains the same. Effective decision making (and subsequent training interventions) depend on understanding the context in which a tissue must operate. A generic program designed to improve tendon function may work, but if the goal is to achieve optimal outcomes, there is no advantage to operating without a comprehensive picture in mind.

After conducting a thorough task analysis to ensure the requirements are solidified as goalposts, non-skilled based staff are largely tasked with two major categories: prevention and performance.

Both are topics worthy of entire seminars themselves. We can’t drill down into the many interesting conversations and nuance each deserves here. Jarred is discussing performance considerations in-depth in his talk- particularly the difficult task of addressing these considerations in-season through the use of a vertical integration framework.

With that in mind, we’ll briefly tackle prevention to complement his presentation and set the stage for deeper discussion in April.

Prevention: Where Intuition and Evidence Diverge

Most individuals in this space likely assume that preventative efforts are effective. When we examine injury reduction from a high vantage point, there is plenty of evidence to support that belief. Lauersen reported that overuse injuries can be reduced by almost 50 percent [5]. Later, when evaluating the importance of strength training specifically, the same group found a dose‑response relationship in which a 10% increase in strength training volume reduced the risk of injury by more than 4% [6].

In general sports populations, pooled analyses consistently showed that exercise‑based prevention programs reduce injuries. Strength, proprioception, balance, neuromuscular training, and psychological interventions all demonstrated benefit [7].

It is relatively easy to form a biological argument for why this should apply to tendon‑related concerns.

Mersmann’s 2023 work showed more than a twofold increase in the development of tendon pain when athletes frequently reached high levels of tendon strain [8]. This aligns with known physiological consequences of repeated high‑strain loading [9]. Under cyclic loading, collagen fibrils progressively lose cross‑links, take on a longer resting length, and become more compliant. When this process is repeated across many fibrils and many loading cycles, it produces the macroscopic structural disorganization that is prospectively associated with future injury across multiple demographics [10, 11, 12].

A more compliant fibril reaches high strain levels sooner and more often, which increases the number of damaging cycles it experiences. This establishes a positive feedback loop where elevated strain exposure drives further disruption and increases the likelihood of tendon pain.

Despite the lack of measurable collagen turnover in carbon‑dating studies [13, 14], tendons clearly adapt to load, showing changes in stiffness, modulus [15], and structural organization across a competitive season [16].

Therefore, it would seem reasonable that interventions which reduce strain (magnitude or frequency of exposure to high‑strain cycles) could limit disorganization and reduce the likelihood of pathological progression.

But caution is warranted. A systematic review by Wang in 2023 [17] not only found no reduction in patellar tendinopathy following prophylactic intervention, but even noted a tendency to elevate the risk. This stands in contrast to a separate systematic review conducted by Burton in 2022, which concluded that resistance training may be a useful prophylactic method [18].

This discrepancy exposes a deeper issue in how preventive evidence is built. Much of the current literature treats fundamentally different athletes, tissues, and loading contexts as if they are interchangeable. In doing so, our evidence base obscures the distinctions that may determine whether an intervention succeeds or fails.

How Do We Reconcile Opposing Messages Across The Literature?

The apparent contradictions in the evidence base become far more coherent when we examine three interacting constraints: who is being loaded, how they are being loaded, and how they adopt their loading strategies to meet their demands.

Patient Selection

Wang describes a “watershed effect” in which the response to prophylactic exercise depends on the tendon’s starting condition [17]. Athletes with abnormal baseline ultrasound findings experienced increased incidence of patellar tendinopathy when exposed to prophylactic loading, whereas those with normal structure experienced reduced incidence.

We have already outlined in earlier editions that tendon mechanics can vary widely even under consistent external loading. While some of this variability reflects non‑pathological differences between athletes, the downstream consequence is the same: individuals who experience higher internal strain are exposed more frequently to the destructive positive feedback loop described above. 

Some athletes enter training with a tendon that is already operating closer to its mechanical limits, which makes standard prophylactic loading effectively an overdose. Standard loading prescriptions may inadvertently push these athletes into high‑strain territory, which helps explain why the same intervention can be protective in some individuals and harmful in others.

Exercise Specificity

Across the two systematic reviews, twelve unique studies were included. Of those twelve, only ten compared conditions where the intervention centered on deliberate loading. Only three incorporated external load, and of those, only two delivered loading sufficient to plausibly reach the strain range associated with adaptive tendon responses (4.5 to 6.5%) [17, 18, 19].

This should give us pause. Our confidence should directly reflect the breadth and quality of the information used as an input. Tendon adaptation is not governed by generic loading. As outlined in Newsletter 2, tendon remodeling depends on stretching collagen fibrils and the surrounding matrix enough to activate mechanotransduction pathways. Across multiple controlled studies, high‑strain conditions consistently increased tendon stiffness, modulus, and region‑specific CSA, whereas low‑strain conditions often produced no adaptation (or even increased strain due to strength gains without tendon remodeling) [19].

Burton’s review directly highlights this issue: “The four studies finding reduced incidence all included progressively loaded isotonic exercises, whereas the study finding no reduction used stretching and unloaded eccentric exercises, which may have been underdosed to derive significant tendon adaptations.”

If strain magnitude is too low, the tendon simply does not respond. This makes it nearly impossible to interpret the magnitude of impact an exercise intervention can have if the mechanical stimulus is not tightly controlled. The broader evidence base is far thinner than it appears at first glance.

Movement Patterns and Load Distribution

Perhaps the largest impact we can have is by bolstering systems that allow us to avoid excessive strain.

Across general populations, proposed modifiable risk factors for tendinopathy show limited and inconsistent support. In Achilles tendinopathy specifically, plantar flexor strength is the only factor with even limited prospective evidence. Other commonly cited characteristics such as ankle dorsiflexion, hip strength, foot posture, BMI and overall activity level demonstrate conflicting or null associations when examined in cohort designs [20]. In basketball‑specific cohorts, no comparable signal exists for Achilles tendinopathy because no sport‑specific prospective studies have identified independent predictors and no variable has survived multivariable adjustment [21].

Prospective risk‑factor studies have produced inconsistent findings, largely because they rarely capture the mechanical exposures or movement strategies that actually shape tendon loading. One of the major omissions in these studies is how athletes actually organize movement, which is where ecological dynamics offers a useful lens.

A central idea within ecological dynamics is the concept of affordances, defined as the opportunities for action that emerge from the interaction between an individual and their environment [22]. Affordances are not fixed properties of the environment but are shaped by the performer’s current action capabilities. As an athlete expands those capabilities, the range of available movement solutions expands accordingly.

A guard with greater speed, strength, and agility is afforded more viable options when attacking a defender. An athlete with more limited physical capacity is constrained to fewer, often more predictable, solutions.

The same logic applies to movement quality: an athlete with greater ankle dorsiflexion range of motion is afforded more ways to perform a cut or landing, enabling them to distribute load across joints and tissues in ways that a more restricted athlete cannot.

Empirical findings reinforce the idea that load distribution meaningfully shapes tendinopathy risk. Two studies included in Burton’s systematic review reported reductions in injury risk even though neither intervention applied external resistance to the tendons in question [23, 24]. Both programs were designed to influence global movement control and body awareness rather than to load the tendon directly.

Steinberg and colleagues extend this idea specifically to the Achilles tendon, but through a different outcome lens [25]. Their 2023 study implemented a prevention program aimed at enhancing somatosensory integration rather than applying mechanical load to the tendon. Although they did not track injury incidence, the intervention group maintained tendon integrity across a high‑volume training period, whereas the control group showed clear structural deterioration.

Collectively, a consistent theme emerges. When athletes are afforded a wider range of movement solutions, the lower limb can share load in more ways during cumulative demands. In that context, high‑strain situations may simply be encountered less often, offering a plausible explanation for why movement‑focused interventions show benefit even without direct tendon loading.

Combining for a Uniform Understanding

The current literature on tendon injury prevention often appears fragmented, but a more cohesive picture emerges when the evidence is viewed through a broader lens. 

The biological rationale for influencing tendon health through targeted loading is strong, yet the current evidence base is not designed to reliably test these principles. These limitations make it difficult to determine how specific interventions influence risk.

As emphasized throughout this series, tendon structure is an imperative consideration.  Baseline mechanical and morphological properties shape how tissues respond to both direct loading and indirect, movement‑focused interventions. 

When these elements are considered together, they point toward a more integrated framework. Tendon structure and function appear to be central determinants of adaptability. Evaluating prevention strategies effectively will require greater specificity in loading prescriptions, clearer mechanobiological alignment, and more deliberate incorporation of structural considerations into both research and practice.

Adequate Tissue Health

As shown above, available evidence suggests that healthy tendons respond favorably to a range of prophylactic interventions. 

When baseline structure is normal, both deliberate tendon-specific loading and more holistic programs that target global movement competencies have shown potential to reduce injury incidence and/or preserve tendon integrity. 

In this context, injury “prevention” can be reasonably inferred using a wide range of interventions. However, we are still operating with an extremely limited evidence base.  Existing studies are poorly controlled and rarely use loading parameters aligned with modern mechanobiological understanding. 

As demonstrated in Burton’s systematic review, generic loading principles likely suffice [18]. However, more controlled loading schemes, such as those employed by Domroes, are preferred [26, 27].

Pre Existing Tissue Disorganization

As structural disorganization accumulates, the tendon approaches a point where its remaining mechanical buffer is too narrow to accommodate the demands of training and sport. Two consequences follow.

1) Standardized loading protocols may impose excessive internal strain.  

When the tendon is already compromised, the same external load can produce disproportionately high internal strain. In this state, loading prescriptions that are protective or adaptive in healthy tissue may instead amplify the mechanical and structural vulnerabilities of the compromised tendon.

2) Indirect offloading strategies may no longer reduce strain enough to matter.  

Movement based interventions rely on the tendon’s ability to take advantage of alternative movement solutions to reduce high strain exposure. Once disorganization crosses a certain threshold, even attempts to redistribute load may not lower tendon strain to a tolerable level. 

A clear demonstration of this threshold comes from Steinberg’s work in combat soldiers [28]. Her team administered the same somatosensory focused prevention protocol discussed earlier across two consecutive infantry commander courses. Unlike the findings from the group’s 2023 intervention (where the protocol helped preserve tendon integrity in athletes who began with organized structure) this cohort saw no protective effect. Diving deeper, the outcomes diverged sharply in this implementation depending on the soldiers’ baseline tendon structure.

Soldiers who began the course with predominantly organized structure showed relatively stable tendon integrity across training. In contrast, those who entered with “high risk” structure (defined as more than 8.5% Achilles echo type III or more than 10% patellar echo type III plus IV) experienced no protective effect at all.

This means there is an inflection point which may initiate differing treatment pathways.

In both moderately and severely compromised tendons, individualized loading parameters are a necessity. Typical prescriptions based on %1RM are very unlikely to maintain adequate strain guardrails on the tissues.

In moderately altered tendons, addressing proprioception and neuromotor strategies during athletic tasks is likely beneficial to aid in the temporary offloading of the Achilles. In cases with more structural deviations, these changes are probably insufficient and more drastic “load management” considerations are warranted.

Unifying the Tendon Prevention Model

Structural integrity determines how tendons respond to load and which strategies can meaningfully influence risk.

This unified understanding helps reconcile the inconsistent messages across the literature. The effectiveness of any intervention depends on the athlete, how they are being loaded, and whether their tendon has enough structural integrity to adopt loading strategies that meet the demands placed upon it.

Conclusion

Effective performance enhancement and preventative efforts begin long before any exercise is selected or any loading parameters are prescribed. They begin with a clear understanding of the athlete, the demands they must meet, and the environment in which those demands are expressed. Without that contextual grounding, even well‑intentioned interventions risk being misaligned with the realities of the athlete’s tissue, their movement solutions, and the constraints that shape their performance. This edition reinforces that point through a structural lens: tendons do not respond to load in isolation. Their adaptability is shaped by the tissue-specific characteristics, the tasks they are asked to solve, and the environments that amplify or alter strain exposure.

With respect to prevention, structural integrity determines the range of strategies that can meaningfully influence risk. When structure is intact, the tendon has the mechanical buffer to absorb, adapt, and reorganize under a wide variety of loading conditions. As disorganization accumulates, that buffer narrows, and the tendon becomes increasingly sensitive to the interaction between external load, internal strain, and the movement strategies available to the athlete. The success of any intervention depends on how well it integrates the athlete’s context with the mechanical realities of their tissue.

Prevention is not a set of exercises, it is a reasoning process anchored in context, capacity, and constraint.

Looking Ahead

In the final edition of the Tendon Summit Insider, we shift gears from decision-making applications in healthy tendons to pathological ones. Presenter Jarrod Antflick’s research contributions will serve as the backdrop for this discussion, as we explore central concepts that matter for clinicians and practitioners navigating the realities of tendinopathy in sporting environments.

- Research review written by: Jason Eure, PT, DPT, OCS, CSCS

Only 3 spots remain for the Summit in April.

Miss a previous edition? Find our archive here.

Reference List 

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