Document Type

Article

Publication Date

5-2-2026

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This article is the author’s final published version in Discover Neuroscience, Volume 21, Issue 1, 2026, Article number 31.

The published version is available at https://doi.org/10.1186/s13064-026-00261-w. Copyright © The Author(s) 2026.

 

Abstract

Introduction: : Chronic tendinopathy affects approximately 30% of musculoskeletal consultations, yet treatment outcomes remain inconsistent despite numerous available interventions. This variability stems from the absence of validated frameworks to match individual patients to optimal treatments based on underlying pathophysiology. To synthesize current evidence on ultrasound imaging biomarkers, neuroimmune mechanisms, and interventional therapies in chronic tendinopathy, and propose a clinically applicable framework integrating ultrasound phenotyping with neuroimmune assessment to guide personalized treatment selection. Methods: A systematic literature search was conducted across PubMed, Scopus, and Web of Science through December 2025. Studies examining ultrasound/elastography imaging, neuroimmune mechanisms, or treatment interventions in chronic tendinopathy were included. Evidence was synthesized qualitatively using narrative synthesis methodology, organized around ultrasound phenotypes, neuroimmune mechanisms, and treatment efficacy stratified by clinical phenotype. Results: Shear wave elastography demonstrates superior diagnostic accuracy (87.5% sensitivity) and treatment monitoring capability (81.3% sensitivity) compared to conventional B-mode ultrasound (3.1% sensitivity for treatment monitoring). Emerging evidence reveals significant neuroimmune involvement, with neoinnervation present in 73% of chronic cases and altered central pain processing manifesting as reduced conditioned pain modulation. Treatment efficacy varies substantially by location and patient phenotype, with platelet-rich plasma showing superiority for lateral epicondylosis and patellar tendinopathy, while extracorporeal shockwave therapy demonstrates location-dependent efficacy. Pain neuroscience education combined with exercise yields greater improvements in pain (weighted mean difference − 2.09/10), disability, and kinesiophobia compared to exercise alone. Conclusions: A three-phenotype framework is proposed: mechanical-degenerative (high-strain loading programs), vascular-neurogenic (neuromodulatory interventions), and central sensitization-dominant (pain neuroscience education with graded activity). This mechanism-based approach shifts clinical decision-making from modality-driven to phenotype-driven treatment selection. Prospective validation through randomized controlled trials is essential to determine whether ultrasound-neuroimmune guided treatment matching improves clinical outcomes and accelerates the transition to precision medicine in tendinopathy management.

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Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Language

English

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