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BJSM Online First, published on August 8, 2015 as 10.1136/bjsports-2015-094849
Editorial

“Rehabilitation will increase the MEASURING CAPACITY IN SPECIFIC

TISSUES
‘capacity’ of your …insert Bone is the musculoskeletal structure that
has the most evidence for its restructure

musculoskeletal tissue here….” with the application of load (especially up

to the end of puberty). We can measure

Defining ‘tissue capacity’: changes relatively easily and structure is

clearly linked to capacity (at least at the

a core concept for clinicians extremes such as osteoporosis). Muscle

bulk can easily be estimated clinically and
measured with imaging but may not be an
JL Cook,1,2 SI Docking2,3 accurate representation of capacity.
Similarly, dynamometry may reflect
aspects of capacity (strength and endur-
Capacity is a helpful term in clinical prac- multiple tissues within the lower limb). ance) but cannot easily measure power.
tice to indicate to clients that they (and After injury, rehabilitation is directed There are no easy measures of tendon
more importantly their musculoskeletal mostly at the injured tissue but specific capacity; even extensively pathological
tissues) are either able or unable to com- rehabilitation may result in synergists or tendons appear to have the capacity to
plete a task or participate in physical activ- unrelated regions being under-loaded, and tolerate very high sporting loads. We
ity. In the context of injury—having this will reduce the capacity of those espouse increasing tendon capacity
exceeded the capacity of the tissue—the tissues. through rehabilitation3 with gradual
term has immediacy for muscle and liga- For example, rehabilitation of a ham- tendon loading that reduces pain and
ment: a musculotendinous or ligament string strain will undoubtedly increase improves function allowing the athlete to
strain is an acute injury due to a loading capacity in the hamstring to sporting cap- return to sport pain-free (figure 1). The
event beyond the tissue’s capacity. The acity. However, capacity in the adductor mechanisms by which the tendon increases
tissue response in tendon is usually more tendons and groin tissue will be reduced if capacity in response to load is unclear as
gradual—acute traumatic injury of normal a progressive change of direction stimulus the tissue pathology may not change.
tendon is rare, whereas the pathological is not included in rehabilitation. The ham- Perhaps we are merely increasing the cap-
tendon can fail catastrophically (rupture). string may be fine (or not), but the groin acity of the normal part of the tendon.4
may fail on return to change of direction Answers to additional key questions
DEFINITION sport such as football. Thus, the initial about tendon capacity, such as, ‘Do
A tissue is at full capacity when the indi- hamstring injury may predispose the groin tendons continue to develop after
vidual is able to perform functional move- to subsequent injury due to reduced cap- puberty?’ and ‘How do they adapt to
ments at the volume and frequency acity in this region. This association increasing loads?’, are unknown. There is
required without exacerbating symptoms between sequential injuries may be unrec- evidence that the collagen in the tendon
or causing tissue injury. The capacity of a ognised if anatomical regions are consid- matrix is stable and has limited turnover
tissue clearly varies between individuals ered in silos. Better data collection after puberty.5 Loading tendon appears to
and the load they place on their tissues. methods are needed to explore possible give different results depending on the
Elite athletes require greater tissue cap- injury associations.1 Clinicians need to be age and gender of the participants;6 again,
acity than recreational players, tissue of thoughtful and skilled in normalising cap- younger tendons appear to be able to
young people has greater capacity than acity across all the soft tissues of the adapt structurally,7 whereas adult tendons
that of older people (all other things kinetic chain after injury to a single tissue. may not change in structure but adapt
being equal) and normal tissue has greater A clinician can build capacity in tissue mechanically.8 Structural adaptation is
capacity than pathological tissue. As func- with considered, gradual overload by pro- easy to understand, with more matrix pro-
tional movements require full capacity in gressing intensity and complexity of teins organised into viable matrix struc-
a number of musculoskeletal tissues, movements specific for that tissue and ture, while mechanical adaptation is less
injury occurs when the capacity of the region. This includes progression to clear as the changes in the tendon that
weakest link in the lower limb is maximal loading—examples of which make it stiffer and more tolerant to higher
exceeded. include high impact loads for bone, loads are unknown.
eccentric contractions for muscle, and
CLINICAL IMPLICATIONS energy storage and release loads for
In the clinical setting, the specificity of tendon. These tissue loads are often deliv- THE OPPOSITE OF CAPACITY—TISSUE
loading tissue to increase capacity is both ered in the same rehabilitation pro- WEAKNESS
simple (load the injured tissue and allow a grammes; imposing high impact on bone The opposite of loading is unloading, and
period for adaptation) and complex (load requires high load on muscle and tendon. the opposite of capacity is tissue weak-
Once the injured musculoskeletal tissue ness. The ‘use-it or lose-it’ phenomenon
1
Centre for Sport & Exercise Medicine, La Trobe
regains capacity, the key consideration is of tissue capacity has been extensively
University, Bundoora, Australia.; 2Australian Centre of to build capacity in the entire lower limb described in bone. While injury may be
Research into Injury in Sport and its Prevention by replicating the movements, loads limited to one tissue, pain and reduced
(ACRISP), Federation University, Ballarat, Australia; (frequency, time, intensity) and skills loading must reduce capacity in associated
3
School of Primary Health Care, Monash University, required in sport. Outmoded passive ther-
Frankston, Australia tissues within the kinetic chain. Failure to
apies, biological injections2 and loading return capacity in all these tissues may
Correspondence to Dr JL Cook, Centre for Sport &
Exercise Medicine, La Trobe University, Bundoora,
that is not progressive cannot deliver this result in reinjury or subsequent injury.
Australia; [email protected] outcome. Understanding the mechanobiology of
Cook JL, Docking SI. Br J Sports Med Month 2015 Vol 0 No 0 1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
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Editorial

Figure 1 Schematic of tendon rehabilitation, improving tendon capacity with progressive loads. Introduction and progression of endurance and
compressive loads are critical within each stage. The start and end points of rehabilitation will vary between individuals.

musculoskeletal tissues, and how loading Br J Sports Med 2015;0:1–2. 4 Docking SI, Cook J. Pathological tendons maintain
and unloading affects the capacity of these doi:10.1136/bjsports-2015-094849 sufficient aligned fibrillar structure on ultrasound tissue
characterization (UTC). Scand J Med Sci Sports 2015.
tissues is critical to clinicians if we are to 5 Heinemeier KM, Schjerling P, Heinemeier J, et al. Lack
rehabilitate resilient athletes. of tissue renewal in human adult Achilles tendon is
REFERENCES revealed by nuclear bomb (14)C. FASEB J
Funding Sean Docking was funded as part of the 1 Finch CF, Cook J. Categorising sports injuries in 2013;27:2074–9.
Monash University Postgraduate Publication Award. epidemiological studies: the subsequent injury 6 Magnusson SP, Hansen M, Langberg H, et al. The
Competing interests None declared. categorisation (SIC) model to address multiple, adaptability of tendon to loading differs in men and
recurrent and exacerbation of injuries. Br J Sports Med women. Int J Exp Pathol 2007;88:237–40.
Provenance and peer review Commissioned; 2014;48:1276–80. 7 Kongsgaard M, Reitelseder S, Pedersen TG, et al.
externally peer reviewed. 2 de Vos RJ, Windt J, Weir A. Strong evidence against Region specific patellar tendon hypertrophy in humans
To cite Cook JL, Docking SI. Br J Sports Med platelet-rich plasma injections for chronic lateral following resistance training. Acta Physiologica
Published Online First: [ please include Day Month Year] epicondylar tendinopathy: a systematic review. Br J 2007;191:111–21.
doi:10.1136/bjsports-2015-094849 Sports Med 2014;48:952–6. 8 Reeves ND, Maganaris CN, Narici MV. Effect of
3 Cook JL, Purdam CR. The challenge of managing strength training on human patella tendon mechanical
Received 23 March 2015 tendinopathy in competing athletes. Br J Sports Med properties of older individuals. J Physiol 2003;
Accepted 17 July 2015 548(Pt 3):971–81.
2014;48:506–9.

2 Cook JL, Docking SI. Br J Sports Med Month 2015 Vol 0 No 0

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''Rehabilitation will increase the 'capacity' of

your …insert musculoskeletal tissue here…
.'' Defining 'tissue capacity': a core concept
for clinicians
JL Cook and SI Docking

Br J Sports Med published online August 8, 2015

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