Nutrition 32 (2016) 617619

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Nutrition
journal homepage: www.nutritionjrnl.com

Review

Nutritional research may be useful in treating tendon injuries

Luke Curtis M.D., M.S. *
Curtis Research, Burnsville, MN

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 4 September 2015
Accepted 25 December 2015

Tendon injures cause a great deal of disability and pain, and increase medical costs. However,
relatively little is known about tendon biology and healing. Many tendon-related surgical procedures are not very successful and leave the patient with essentially a chronic injury. New
therapeutic approaches for tendon injury are needed. Preliminary evidence suggests that various
nutrients such as proteins, amino acids (leucine, arginine, glutamine), vitamins C and D, manganese, copper, zinc, and phytochemicals may be useful in improving tendon growth and healing.
More research on nutrition and tendon health is needed. Because many nutrients are required for
tendon health, nutritional interventions involving multiple nutrients may be more effective than
single-nutrient strategies. In the future, ideal treatment regimens for tendon injuries may include a
multifaceted bundle of nutrition, drugs, biologic products, extracellular matrix therapies, exercise/physical therapy, and possibly surgery.
2016 Elsevier Inc. All rights reserved.

Keywords:
Tendon
Achilles tendon
Rotator cuff
Tenocytes
Vitamin C
Amino acids
Manganese
Copper
Zinc
Phytochemicals

Introduction
Tendon injuries cause a great deal of pain and disability, as
well as increasing medical and economic costs [1,2]. The exact
prevalence of tendon injuries is unknown, but it is estimated that
worldwide >30 million individuals have tendon-related surgical
procedures annually at a medical cost of w$196 billion [3]. Surgical repairs for tendon injuries require a long and painful
recuperation and often are not very successful, leaving the patient with essentially a permanent injury [37]. Clearly, better
treatments for tendon injuries are needed.
Tendon healing is generally a very slow and incomplete process [1,68]. Use of biologic and biomaterial approaches, such as
use of platelet-rich plasma, extracellular matrix (ECM)/scaffold
treatments, regulation of growth factors and cytokines, and stem
cellbased approaches, potentially offer promise in speeding up
and improving repair of torn or otherwise damaged tendons [1,3,
5,8,9]. There is a dearth of both basic and applied tendon
research, and our basic understanding of tendon biology lags far
behind that of muscle or bone [1,2,6,7].
The purpose of this short review is to describe existing
research on nutrition and tendon health/healing and to stimulate

* Corresponding author. Tel.: 1 952 513 7568.

E-mail address: Luketcurtis@aol.com
http://dx.doi.org/10.1016/j.nut.2015.12.039
0899-9007/ 2016 Elsevier Inc. All rights reserved.

interest in clinicians and researchers to consider nutritional

approaches as a partial strategy in treating tendon problems.
Materials and methods
Approximately 110 research and review articles were collected for information about studies relating to tendons with nutrition and related topics. Animal
and cell culture studies were included as in vivo studies of nutrition and tendons
in humans are currently sparse. Various medical databases were searched,
including PubMed, Google and Google Scholar, fda.gov, and clinicaltrials.gov. No
time restriction was placed on the search. Searched terms included a variety of
tendon-related terms including tendon, tendonitis, tendon tears, Achilles tendon,
rotator cuff, patellar tendon, tenocytes, collagen, leucine rich proteins, and proteoglycans. Many nutrition-related terms were also used including calories, u-3
fats, protein, amino acids (such as leucine, glutamine, arginine, and taurine), fruits,
vegetables, phytochemicals, vitamins (including all of the various vitamins), minerals (calcium, manganese, zinc, copper, magnesium, iron, molybdenum, and
silicon), and coenzyme Q10. Thirty-three articles were selected for this review
once they were deemed to have relevance in exploring relationships between
tendons and nutrition.
Nutrition and tendon growth and healing
Nutrition may play a major role in tendon healing, although research has
been sparse to date. The majority of work has involved animals or cultured human cells, although there are a few clinical human studies. Some animal and
human studies report signicantly better tendon growth or collagen synthesis
after various nutritional interventions. Supplementation with 19.5 g/d of whey
protein was found to signicantly increase the patellar and quadricep tendon
cross-sectional area in a group of 22 men concurrently in an exercise program
[10]. Vitamin C is necessary for the enzymatic synthesis of both collagen proteins
and several proteoglycans found in tendons [11]. Vitamin C also is a

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L. Curtis / Nutrition 32 (2016) 617619

Table 1
Human, animal, and cell culture studies, which suggest nutrients may be helpful in tendon health, growth, and repair and/or collagen synthesis
Nutrient

Human
studies*

Animal studiesmammals
or birds

Cell culture studies

or animal organs

Whey protein
Vitamin C
Vitamin D
Glucosamine/chondroitin sulfate
Taurine
Biotin, folate, manganese
Calories
Protein
Glutamine, arginine, leucine, isoleucine, valine
Tenosan 1 g of arginine l-a-ketoglutarate, 1.1 g methylsulfonylmethane,
600 mg hydrolyzed collagen, 120 mg vitamin C, and 100 mg bromelain daily
Cyanidin (phytochemical found in many fruits and vegetables)
Curcumin
Magnesium
Vitamin C, collagen type 1, manganese, and mucopolysaccharides
Eicospentaenoic acid (u-3 fatty acid)

[10]

[11]
[11]

[25,26]

[12]
[13]
[14]
[15]
[16]
[11]
[11]
[20]

[27]
[28]
[29]
[30]
[31]

Numbers in brackets refer to references.

transcriptional promoter of collagen synthesis [12]. A rat study reported that

high-dose oral vitamin C supplementation signicantly accelerated healing of
ruptured Achilles tendons [12]. Another rat study reported that a vitamin Ddecient diet signicantly slowed healing and buildup of biomechanical strength
of the rotator cuff [13]. High-dose oral glucosamine/chondroitin sulphate was
found to signicantly accelerate tendon and bone healing in rabbits [14]. Taurine
injected at the tendon repair site was found to signicantly improve load
strength in rats with repaired Achilles tendons [15]. Deciencies of biotin, folate,
or manganese were found to signicantly increase tenosynovitis in reovirusinfected chickens [16].
Because collagen forms the major extracellular protein in tendons, muscle,
and ligaments [1,11,17], dietary interventions to increase collagen synthesis,
protein synthesis, or both in general may be helpful in rebuilding tendons. Such
dietary interventions might include providing sufcient overall calories or protein and supplementation with such nutrients as trace minerals, amino acids, or a
combination of both. Numerous animal and human studies have reported that
diets decient in protein, calories, or both lead to signicantly less collagen
production [11]. Many trace minerals such as zinc, copper, and manganese play a
key role in collagen metabolism, and nutritional deciencies in these minerals
have been linked to poorer collagen synthesis [18,19]. Amino acid supplementation with glutamine, arginine, and branched-chained amino acids (leucine,
isoleucine, and valine) was found to signicantly increase skin collagen synthesis
in ultraviolet-irradiated mice [20]. Various studies have reported that dietary
consumption of leucine or its metabolite b-hydroxy-b-methylbutyrate simulate
protein synthesis via signaling pathways involving mammalian target of rapamycin in a doseresponse manner [21]. Other studies have reported that oral
supplementation of mixtures of b-hydroxy-b-methylbutyrate, glutamine, and
arginine can signicantly increase muscle, lean mass, or both in a wide variety of
patients including the elderly [22], cachectic HIV patients [23], and
muscle-wasted cancer patients [24].
Because many nutrients are involved with tendon and collagen metabolism,
nutritional interventions employing multiple nutrients may yield better results
compared with studies employing only one nutrient. A study of 90 patients with
rotator cuff surgery reported that the use of a multifaceted Tenosan supplement
containing 1 g of arginine l-a-ketoglutarate, 1.1 g methylsulfonylmethane,
600 mg hydrolyzed collagen, 120 mg vitamin C, and 100 mg bromelain daily was
associated with signicantly better repair integrity at nal follow-up [25]. A
study of patients with insertional Achilles tendinopathy treated 32 patients with
the Tenosan supplement and 32 with placebo. All patients also underwent three
courses of extracorporeal shockwave therapy. After 6 mo, pain was signicantly
reduced and patient satisfaction was signicantly increased in the Tenosantreated patients compared with the placebo-treated patients [26].
In vitro studies also suggest that various nutrients like phytochemicals from
plants or u-3 fats may be useful for tendon repair and health. Cyanidin is a
colored pigment found in many fruits and vegetables including red cabbage,
cherries, bilberries, serviceberries, red and black grapes, blueberries, and blackberries. Cyanidin (100 mg/mL) was found to inhibit autophagic cell death in human rotator cuff tenoblasts [27]. Curcumin (a diarylheptanoid found in turmeric)
was found to signicantly reduce inammation in human tenocytes [28]. A study
of Achilles tendons from orooxicin-treated rats reported that degenerative
changes were signicantly more common in rats fed a magnesium-decient diet
compared with a magnesium-sufcient diet [29]. A supplement containing
vitamin C, collagen type 1, manganese, and mucopolysaccharides showed signicant antiinammatory and anticatabolic effects of human tenocytes in vitro

[30]. The u-3 fatty acid eicospentaenoic acid was found to enhance collagen
formation in cultured human medial collateral ligament broblasts [31].
Proteoglycans are proteins found in the tendons extracellular matrix (ECM),
which play a critical role in the function and structure of tendons. The two main
classes of tendon proteoglycans include:
1. The small leucine-rich proteoglycans (SLRPs) including decorin, bromodulin, lumican, and biglycan. These proteins bind to collagen brils.
2. Large molecular proteoglycans such as aggrecan and versican, which are
associated with tendon loading and mobilization [32,33].
Perhaps nutritional interventions with leucine or other nutrients may
improve synthesis and function of tendon proteoglycans. Understanding of the
relationships between nutrition and tendon proteoglycans is lacking and major
research in this area is clearly needed.
Table 1 summarizes various human, animal, and cell culture studies which
suggest that various nutrients may be helpful to tendon health, growth, or repair.

Conclusion
More research and clinical attention is needed to develop
better treatment strategies for torn or damaged tendons. Most of
the research on tendons and nutrition has dealt with animal or
cell culture studies, which may or may not be representative of
the effects of nutrition and tendon health in humans. Additional
research on human nutrition and tendon health and repair is
needed. Most nutritional interventions are fairly inexpensive and
have a low risk of side effects. A bundle of multiple interventions may be needed for optimal tendon growth and
healing. In the future, ideal treatment for tendon injuries may
include a multifaceted program of good nutrition/supplements,
drugs, biologic products/stem cells, extracellular matrix/scaffold
therapies, exercise/physical therapy, and possibly surgery.
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