title: Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults.
abstract: BACKGROUND
  The present article systematically reviews recent literature on the in vivo adaptation of asymptomatic human tendons following increased chronic mechanical loading, and meta-analyzes the loading conditions, intervention outcomes, as well as methodological aspects.
  
  
  METHODS
  The search was performed in the databases PubMed, Web of Knowledge, and Scopus as well as in the reference lists of the eligible articles. A study was included if it conducted (a) a longitudinal exercise intervention (≥8 weeks) on (b) healthy humans (18 to 50 years), (c) investigating the effects on mechanical (i.e., stiffness), material (i.e., Young's modulus) and/or morphological properties (i.e., cross-sectional area (CSA)) of tendons in vivo, and was reported (d) in English language. Weighted average effect sizes (SMD, random-effects) and heterogeneity (Q and I2statistics) of the intervention-induced changes of tendon stiffness, Young's modulus, and CSA were calculated. A subgroup analysis was conducted regarding the applied loading intensity, muscle contraction type, and intervention duration. Further, the methodological study quality and the risk of bias were assessed.
  
  
  RESULTS
  The review process yielded 27 studies with 37 separate interventions on either the Achilles or patellar tendon (264 participants). SMD was 0.70 (confidence interval: 0.51, 0.88) for tendon stiffness (N=37), 0.69 (0.36, 1.03) for Young's modulus (N=17), and 0.24 (0.07, 0.42) for CSA (N=33), with significant overall intervention effects (p<0.05). The heterogeneity analysis (stiffness: I2=30%; Young's modulus: I2=57%; CSA: I2=21%) indicated that differences in the loading conditions may affect the adaptive responses. The subgroup analysis confirmed that stiffness adaptation significantly (p<0.05) depends on loading intensity (I2=0%), but not on muscle contraction type. Although not significantly different, SMD was higher for interventions with longer duration (≥12 weeks). The average score of 71±9% in methodological quality assessment indicated an appropriate quality of most studies.
  
  
  CONCLUSIONS
  The present meta-analysis provides elaborate statistical evidence that tendons are highly responsive to diverse loading regimens. However, the data strongly suggests that loading magnitude in particular plays a key role for tendon adaptation in contrast to muscle contraction type. Furthermore, intervention-induced changes in tendon stiffness seem to be more attributed to adaptations of the material rather than morphological properties.
authors.affiliation: Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Philippstr. 13, Haus 11, 10115, Berlin, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Bohm
authors.affiliation: Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Philippstr. 13, Haus 11, 10115, Berlin, Germany.
authors.forename: Falk
authors.initials: F
authors.lastname: Mersmann
authors.affiliation: Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Philippstr. 13, Haus 11, 10115, Berlin, Germany. a.arampatzis@hu-berlin.de.
authors.forename: Adamantios
authors.initials: A
authors.lastname: Arampatzis