Obesity as a Risk Factor for Tendinopathy: A Systematic Review

Table 1

Summary of the studies.

Authors	Year	Tendinopathy	Study design	Number of patients	Age in years (range)	Measures of obesity	Relevant results	Conclusions of the study	Association
Wendelboe et al. [14]	2004	Rotator cuff	Frequency-matched case-control study; Prognostic study,; Level II	311 RCR cases versus 993 controls	(53–77)	BMI	OR: 1.9 (95% CI: 1.1–2.2) for males and 2.4 (1.4–4.2) for females with BMI ≥ 35.; OR: 3.1 (95% CI: 1.3–7.6) for males and 3.5 (1.8–6.9) for females with BMI ≥ 35.; Risk directly correlated with the grade of obesity for both men () and women ()	Obesity increases risk to need RCR	Yes
Rechardt et al. [19]	2010	Rotator cuff	Cross-sectional study (population study)	6,237 of which chronic 28 (2.8%) with RC tendinitis	50.8 for men, 52.9 for women (>30)	BMI,; waist circumference,; waist-to-hip ratio	WC 94.0–101.9 cm and RC tendinitis; OR: 2.0 (1.1–3.5) in men	Increased WC is associated with chronic RC tendinitis in men	Partial
Titchener et al. [23]	2014	Rotator cuff	Retrospective case-control, treatment study; Level III	5,000 cases of RC disease versus 5,000 controls; (BMI calculated in 3,385 of cases (67.7%) and 3,050 (61.0%) of controls)	55; (interquartile range 44–65)	BMI	BMI 25.1–30 (overweight) and RC disease OR: 1.23 (1.10–1.38); BMI 30.1–40 (obese) and RC disease OR: 1.25 (1.09–1.44); BMI > 40 (morbidly obese) no increased risk; After adjustment for consultation rate, the effect persisted only in the BMI 25.1–30 (overweight) group OR: 1.15 (1.02–1.31)	Significant association only for patients who are slightly overweight (BMI 25–30); Impossible to differentiate comorbid factors such as diabetes mellitus, atherosclerosis, and hyperlipidemia	Partial
Titchener et al. [24]	2013	Epicondylitis (lateral and medial)	Retrospective case-control, treatment study; Level III	4998 versus 4998 controls; (BMI calculated in 3,449 of cases (69%) and 3,049 (61.0%) of controls)	49; (interquartile range 42–56)	BMI	BMI > 40 and lateral epicondylitis OR: 1.41 (1.01–1.97); The effect disappeared when BMI was adjusted for consultation rate	Obesity is not associated with epicondylitis	No
Descatha et al. [28]	2013	Epicondylitis (lateral and medial)	Case-series (longitudinal study); Level IV	699 workers with no symptoms at baseline.; At 36 months: 48 suffered from medial or lateral epicondylitis (6.9%), 34 from lateral epicondylitis (4.9%), 30 from medial epicondylitis (4.3%), and 16 from both	38.1 ± 9.3 (20–66)	BMI	BMI > 30 and lateral epicondylitis: univariate analyses OR: 2.4 (1.2–4.8), multivariate analyses OR: 1.8 (0.8–3.9).; No association for medial epicondylitis	Obesity is associated only with lateral epicondylitis	Partial
Shiri et al. [20]	2006	Epicondylitis (lateral and medial)	Cross-sectional study (population study)	4,783 of the initial 5,871 (81.5%); 67 with lateral epicondylitis (1.3%) and 19 with medial epicondylitis (0.4%)	46.3 ± 9.6 (30–64)	BMI,; waist circumference	Only in women; WC > 100 cm and medial epicondylitis OR: 2.7 (1.2–6.0); BMI > 30 kg/m^2 and medial epicondylitis OR: 1.9 (1.0–2.7); No association for lateral epicondylitis	Obesity is associated with medial epicondylitis.	Partial
Alvarez-Nemegyei [25]	2007	Pes anserinus	Retrospective case-control study; Level III	22 cases of tendinopathy versus 38 controls	62.1 ± 11.5 for cases, 59.8 ± 9.4 for controls	BMI	Obesity: case 16/22 (72.7), controls 21/38 (55.3), nonsignificant	No association	No
Taunton et al. [27]	2002	Patellar tendon	Retrospective case-control study; Level III	96 cases versus 1906 controls	34.3	Weight,; BMI	No association	No association	No
Frey and Zamora [21]	2007	Achilles, posterior tibial, and peroneal tendon	Cross-sectional study (population study)	1411 of which; 208 with tendinitis/tendinosis	>18	BMI	123 (65.4%) of the overweight/obese subjects had a diagnosis of tendinitis compared to 65 (34.6%) normal subjects.; BMI > 25 and tendinitis OR: 1.923 (1.39–2.66)	Being overweight or obese significantly increased the chances of tendinitis	Yes
Holmes and Lin [26]	2006	Achilles	Retrospective case-control study,; Level III	82 cases	49.5 (27–77)	BMI	Obesity was statistically associated with Achilles tendinopathy for women and for men, respectively	Obesity is one of the etiological factors of the Achilles tendinopathy	Yes
Gaida et al. [22]	2010	Achilles	Population-based study (cross-sectional study)	298 cases (127 men, 171 women) asymptomatic Achilles tendinopathy in 17 men (13%) and 8 women (5%) ().	Men 38.3 ± 12.2; Women 36.5 ± 10.5	Fat distribution (android/gynoid fat mass ratio and upper body/lower body fat mass ratio) determined using WC, WHR, and dual-energy X-ray absorptiometry	Men with Achilles tendinopathy had greater WHR (0.926 ± 0.091, 0.875 ± 0.065, ), higher android/gynoid fat mass ratio (0.616 ± 0.186, 0.519 ± 0.142, ), and higher upper body/lower body fat mass ratio (2.346 ± 0.630, 2.022 ± 0.467, ).; Women with tendinopathy had less total fat (17196 ± 3173 g, 21626 ± 7882 g, ), trunk fat (7367 ± 1662 g, 10087 ± 4152 g, ), and android fat (1117 ± 324 g, 1616 ± 811 g, ). They had lower central/peripheral fat mass ratios (0.711 ± 0.321 g, 0.922 ± 0.194 g, ) than women with normal tendons	Men with Achilles tendinopathy had a central fat distribution.; Women had a peripheral fat distribution.	Yes
Scott et al. [15]	2013	Achilles	Frequency-matched case-control study; Prognostic study,; Level II	197 cases versus 100 controls	Cases: 52.77 ± 11.8 (21–82); Controls: 42.74 ± 12.1 (21–78)	BMI	Significant difference in BMI: 34.69 ± 7.54 (17.9–75.9) versus 30.56 ± 7.55 (19.7–61-5)	Patients with Achilles tendinopathy exhibited a significant higher BMI than controls	Yes
Klein et al. [16]	2013	Achilles	Frequency-matched case-control study; Prognostic study,; Level II	472 cases versus 472 controls	Cases: 51.2 ± 13.5 (16–88); Controls: 52.0 ± 14.3 (18–88)	BMI	OR: 2.60, 95% CI = 1.87–3.61; 3.81, 95% CI = 2.57–5.63; 3.77, 95% CI = 2.24–6.34; 6.56, 95% CI = 3.18–13.55; For BMI: 25.0–29.9, 30.0–34.9, 35.0–39.9, and >40.0, respectively	BMI plays a role in the development of Achilles tendinopathy	Yes
Taunton et al. [27]	2002	Achilles	Retrospective case-control study,; Level III	96 cases versus 1906 controls	40.7	Weight,; BMI	No association	No association	Np
Taunton et al. [27]	2002	Plantar fascia	Retrospective case-control study,; Level III	158 cases versus 1846 controls	41.8	Weight,; BMI	Weight >60 kg in female OR: 0.378 (0.203–0.706)	Women with a body weight greater than 60 kg were at increased risk of experiencing plantar fasciitis	Partial
Irving et al. [17]	2007	Chronic plantar heel	Frequency-matched case-control study; Prognostic study,; Level II	80 cases versus 80 controls	52.3 ± 11.7	BMI	Significantly greater BMI for CPHP group (29.8 ± 5.4 kg/m^2 versus 27.5 ± 4.9 kg/m^2; ); CPHP were more likely to be obese (OR: 2.9, CI: 1.4–6.1, )	Obesity is associated with chronic plantar heel pain	Yes
Frey and Zamora [21]	2007	Plantar fascia	Cross-sectional study (population study)	1411 of which; 189 with plantar fasciitis	>18	BMI	208 affected by plantar fasciitis; BMI > 25 and plantar fasciitis OR: 1.4 (1.016–1.93)	If the subjects were overweight or obese, there was an increased likelihood, although not significant, of plantar fasciitis	No
Riddle et al. [18]	2003	Plantar fascia	Frequency-matched case-control study; Prognostic study,; Level II	50 cases versus 100 controls	49 ± 11 (31–85)	BMI	BMI > 30 OR: 5.6 (CI: 1.9–16.6) compared with the BMI ≤ 25 kg/m^2	Obesity appears to be independent risk factor for plantar fasciitis.	Yes

BMI: body mass index; WC: waist circumference; WHR: waist-to-hip ratio; OG: group of obese patients; CG: control group; RC: rotator cuff; RCR: rotator cuff repair; CPHP: chronic plantar heel pain; OR: odds ratio; CI: confidence interval; and n.r.: not reported.