Which of the following statements about tendon injuries and repair is true?

Tendon Injuries and Repair: Statement Analysis

The correct answer is D: Tendinosis can be painless. This statement is true based on the evidence that chronic degenerative tendon changes (tendinosis) can exist without causing symptoms, as demonstrated by clinical and ultrasonographic findings that are not clearly related to patients' symptoms 1, 2.

Analysis of Each Statement

Statement A: Strength Normal Within 3 Months - FALSE

• Most patients with overuse tendinopathies require 3-6 months for full recovery, not for complete strength normalization 1.
• Approximately 80% of patients fully recover within this timeframe, but this refers to functional recovery and symptom resolution, not complete restoration of tendon strength 1, 3.
• Long-term follow-up studies demonstrate that even 8 years after treatment, clear side-to-side differences persist on performance testing and clinical examination, indicating that structural and functional deficits can remain despite symptom resolution 2.
• The healing timeline extends well beyond 3 months for true structural recovery, making this statement incorrect 1.

Statement B: Healing by Distal Degeneration and Proximal Regrowth - FALSE

• This statement misrepresents tendon healing biology and is not supported by the evidence provided.
• Tendons heal through intrinsic cellular mechanisms involving tenocytes and collagen remodeling throughout the damaged tissue, not through a proximal-to-distal regeneration pattern 1.
• The pathophysiology involves degenerative changes in the densely arranged collagen fiber structure with hypercellularity and vascular proliferation, not sequential degeneration and regrowth 1, 4.

Statement C: Paratendinitis Has Good Prognosis - PARTIALLY TRUE BUT MISLEADING

• While paratendinitis can resolve with appropriate treatment, the evidence shows it is associated with more pronounced inflammatory responses and can complicate the clinical picture 4, 5.
• Paratendinitis often accompanies tendon degeneration and may accelerate tendinosis-like changes, particularly when inflammatory mediators like substance P are involved 4, 6.
• Cold weather training significantly increases the risk of Achilles paratendinitis (9.4% in winter versus 3.6% in summer), suggesting environmental factors can worsen prognosis 5.
• The statement oversimplifies the condition—while many patients recover, paratendinitis can be a complicating factor rather than a benign condition with uniformly good outcomes 4, 5.

Statement D: Tendinosis Can Be Painless - TRUE

• This is the correct answer based on strong evidence from long-term follow-up studies 2.
• At 8-year follow-up, mild-to-moderate changes were observed on clinical and ultrasonographic examinations in both involved and initially uninvolved Achilles tendons, but the occurrence of these changes was not clearly related to patients' symptoms 2.
• The underlying pathology of most chronic tendon problems is degenerative tendinopathy (tendinosis) rather than acute inflammation, and these degenerative changes can exist without causing pain 1, 3.
• This explains why patients may have structural abnormalities on imaging without corresponding symptoms, a clinically important distinction 2, 6.

Clinical Implications

• Avoid mislabeling chronic cases as "tendinitis" when they represent degenerative tendinopathy ("tendinosis"), as this affects treatment approach 1, 3.
• The presence of imaging abnormalities does not necessarily correlate with symptoms, so treatment decisions should be guided by clinical presentation rather than imaging findings alone 2, 6.
• Most patients (approximately 80%) achieve full functional recovery within 3-6 months with conservative management consisting of relative rest, ice therapy, and eccentric strengthening exercises 1, 3.