Tendinopathy Rehab and Metabolic Health: Why Loading Alone Isn’t Enough
“Just load it”, right?
That’s been the dominant narrative for managing tendinopathy: progressive loading with the goal of building up the capacity of the tendon. Common protocols like the Alfredson eccentric program and Heavy Slow Resistance (HSR) training are well-supported by research and utilized as the primary treatment approach. And while this biomechanical approach is effective for many patients, it’s increasingly clear that tendinopathy is not just a local overuse issue. It can also be a systemic one.
Metabolic Health: A Missing Piece in Tendon Rehab
A large-scale population-based study by Skovgaard et al. investigated the relationship between metabolic markers and tendon injuries, specifically in individuals with Achilles tendinopathy. (1)
The study found the following associations between metabolic health and tendon injury risk:
Prediabetic A1c levels (greater than 5.7%) were associated with a threefold increase in the risk of lower extremity tendon injuries
Hypercholesterolemia significantly increased the risk of upper extremity tendon injuries, including rotator cuff involvement
Individuals with metabolic syndrome had a two-to-threefold greater risk of tendon injuries in both weight-bearing and non-weight-bearing regions
Further research on rotator cuff tendinopathy has also shown (2):
Diabetes, obesity, and dyslipidemia are linked to a higher incidence of rotator cuff pathology
Metabolic syndrome is associated with increased tendon thickness and larger tear sizes
Patients with metabolic conditions are more likely to present with bilateral tears
These cases are often less responsive to conservative treatment, suggesting a systemic influence on tendon quality and healing
These findings emphasize the importance of considering metabolic health as a modifiable risk factor, not just a background medical condition.
Function Follows Physiology: Impaired Tendon Mechanics in Diabetes
A study by Petrovic et al. examined Achilles tendon function during walking in individuals with diabetic neuropathy and revealed several mechanical deficits (3):
Increased tendon stiffness
Reduced capacity to store and release elastic energy during gait
Higher hysteresis, meaning more energy was lost as heat
Increased muscular demand during walking, contributing to fatigue and reduced efficiency
These changes demonstrate how metabolic dysfunction not only alters tendon structure but also impairs function during everyday movement. This is an important consideration when designing rehabilitation plans.
Clinical Implications for Rehab
For evidence-based chiropractors, the takeaway is clear: loading is essential, but not always sufficient.
Patients with early or undiagnosed metabolic dysfunction may present with tendon symptoms that are resistant to standard loading protocols
Chronic hyperglycemia and dyslipidemia can impair tendon healing, alter collagen structure, and increase stiffness, particularly after periods of inactivity
In patients with persistent, recurrent, or bilateral tendinopathies, consider screening for metabolic conditions like hyperglycemia and hypercholesterolemia
Interprofessional collaboration with primary care providers may support more comprehensive and effective care
In addition to appropriate loading and metabolic screening, consider recommending a tendon-friendly anti-inflammatory diet that’s low in refined carbohydrates, cholesterol, and unhealthy fats.
ChiroUp subscribers have easy access to patient-friendly infographics in the forms library, including guides on the DASH and Mediterranean diets, to help support better nutritional choices.
Certain supplements may also be beneficial, including MSM, collagen, amino acids, vitamin C, bromelain, glucosamine, and Boswellia—all of which have emerging research supporting their role in connective tissue health. (4)
Bottom Line
Tendons do not exist in isolation. While progressive loading remains a foundational part of tendinopathy rehab, clinicians must also recognize the role of systemic health. Addressing metabolic dysfunction may be the missing link in optimizing long-term tendon recovery and resilience.
As evidence-based chiropractors, it’s our responsibility to stay current, think holistically, and empower every patient who walks through our doors. That means doing more than just assessing, treating, and prescribing exercises—it means providing world-class resources that help patients take control of their health. Because educated patients become compliant patients, and compliant patients get better outcomes.
💡 ChiroUp makes that easy.
Inside the Forms Library, you’ll find hundreds of ready-to-use infographics like the ones above—condition rack cards, exam forms, nutrition guides, and much more. Everything you need to educate, engage, and elevate your care is right there.
✅ Already a subscriber? Don’t sleep on this resource. Log in and explore your Forms Library today.
🚀 Not a subscriber yet? Get started—it’s free.
-
Skovgaard D, Siersma VD, Klausen SB, Visnes H, Haukenes I, Bang CW, Bager P, Grävare Silbernagel K, Gaida J, Magnusson SP, Kjaer M. Chronic hyperglycemia, hypercholesterolemia, and metabolic syndrome are associated with risk of tendon injury. Scandinavian journal of medicine & science in sports. 2021 Sep;31(9):1822-31.
Burne G, Mansfield M, Gaida JE, Lewis JS. Is there an association between metabolic syndrome and rotator cuff-related shoulder pain? A systematic review. BMJ open sport & exercise medicine. 2019 Dec 6;5(1).
Petrovic M, Maganaris CN, Deschamps K, Verschueren SM, Bowling FL, Boulton AJ, Reeves ND. Altered Achilles tendon function during walking in people with diabetic neuropathy: implications for metabolic energy saving. Journal of applied physiology. 2018 May 1;124(5):1333-40.
Fong, D. T.-P., et al. (2022). “Metabolic Dysfunction and Tendon Health: Mechanisms and Clinical Implications.” Journal of Clinical Medicine, 11(6), 1666.
