Tendon Investment Framework

​Study Title: 
Tendon Investment Framework: a new communication model for navigating load, symptoms and behaviour in tendinopathy

Authors: 
Anthony Michael Nasser, Max Edward Hopes & Alison Grimaldi

Publication Information: 
British Journal of Sports Medicine (2026) 

Background Information:
Tendinopathy management is often approached through a biomedical lens, though many of the challenges encountered during rehabilitation may be related to how patients respond to symptoms, uncertainty and changes in load. Everyone has their own unique experience.

Some push through escalating symptoms. Others withdraw at the first sign of discomfort. And some fluctuate between the two.

These responses may be influenced by previous experiences, interpretation of symptoms and identity-linked goals. As such, effective tendinopathy management may require an understanding of the person as much as the condition itself. A biopsychosocial approach.

The authors propose the Tendon Investment Framework, a behavioural communication model that reframes tendinopathy management through the lens of investment psychology. Patients are viewed as investors whose personal risk tolerance, interpretation of signals and identity-linked motivations influence how load is invested in the tendon. The clinician, conversely, functions as the advisor. 

Cross-Pollination. I like it!

Disclaimer, this framework does not propose a new treatment strategy. Instead, it provides a structured means of understanding patient responses to loading and tailoring the communication surrounding existing treatment. 

The Three Investor Types:
The framework describes three characteristic investor types based on how patients respond to symptoms, uncertainty and changes in load. 

The Overloader:
Similar to an aggressive investor, the Overloader seeks rapid returns, pushes through symptoms and often has an identity that’s closely tied to performance. Their motivation and tolerance for discomfort can be advantage to them, but these same characteristics can lead to warning signs being ignored and flare-ups being viewed as acceptable collateral. Clear boundaries, symptom thresholds and predefined progression criteria are therefore important. 

The Underloader:
These patients are the risk-averse investors. Symptoms, to them, may be taken as signs of threat, resulting in avoidance, reduced activity and limited confidence in the tendon's capacity. Reassurance, predictable progression, acceptable symptom ranges, early wins and graded exposure can help build confidence and reduce fear-driven disengagement. 

The Oscillator:
The boom-bust investor. Loading decisions are driven largely by how symptoms feel in the moment, pushing on good days and pulling back on the not so good days. The sail with the wind-ers who, unfortunately, sometimes get caught in gale-force winds. Shared planning, consistent messaging and pre-agreed progression rules can help reduce this day-to-day reactivity.
​

Adapted from Nasser, Hopes & Grimaldi (2026).

Applying the Framework:
Once the patient or athlete's characteristic investment pattern is identified, the clinician can tailor communication and education accordingly.

Overloaders need boundaries and symptom thresholds.
Underloaders need reassurance and predictable steps.
Oscillators need consistency and pre-agreed adjustment rules. 

From there, the clinician and patient codesign the rehab plan. Instead of simply handing them a prescription or program, the patient is actively involved in establishing acceptable symptom ranges, loading levels, progression criteria, longer-term timelines and strategies for navigating uncertainty. 

Personally, I like using a whiteboard when working with patients in these scenarios, working through gradual and progressive activity-specific loading, particularly of the things they're already doing.

The aim is to provide structure around how decisions about load are made, with activities that are relevant to them.

Adapted from Nasser, Hopes & Grimaldi (2026).

A Communication and Clinical Reasoning Framework:
​The authors are deliberate in pointing out that the Tendon Investment Framework is NOT a new intervention or treatment strategy. Rather, it is a communication and clinical reasoning layer, grounded in existing literature, that can be applied to the treatments we already use. 

Perhaps more importantly, the framework challenges a common clinical tendency to attribute poor outcomes to the patient:

They did too much.
They didn't listen.
They couldn't stick to the plan.

Instead, the authors suggest that these may be somewhat predictable behavioural responses that can be anticipated and planned for. The astute clinician can then tailor communication and codesign rehabilitation around these behaviours to support more sustainable progress. 

Maybe non-adherence isn't always the problem. Maybe anticipating behaviour is part of the solution.

Significance (at least to me):
What I particularly like about this (cross-pollination style) framework is the relationship between the patient/athlete and clinician. It's a two-way street. Guided, but collaborative.

The patient is the investor. We are the advisor.

I know (hope) we’re already doing this. It’s just a nice framework.

After all, patients and athletes are coming to us for professional services. Our job is to provide guidance, but ultimately, the investment is theirs.

In the athletic setting, it may be easy to assume that most athletes are Overloaders. They may be.
But anecdotally, I think many are Oscillators. If not a combination of the first and third (Overloaders and Oscillators).

And maybe they’re Oscillators (or Overloaders, or Underloaders) because of us.

I have no data to support this. Just my own experience and opinion.

I also wonder if there are other categories that might fall in this framework as well. Likely?
​
Training is rarely static. Neither are symptoms. Athletes push when they feel good, pull back when they don't, and their response to essentially the same external load can change from one day to the next.

Perhaps this is where technology becomes increasingly useful.

Tools such as Catapult can quantify external load, while measures such as heart rate and session RPE can provide information about internal load. But capturing the true individual cost of that work remains challenging. 

We tend to be pretty good at measuring what the athlete did.

The harder question may be:

What did it cost them? The taxes.

I think we're collectively doing a good job overall. I'm just not sure we've completely figured out how to quantify those taxes yet. And this actually may be important, since in many of the environments in which I work, there isn't just one advisor.

​Patients and athletes may be co-managed alongside sport medicine physicians, interventional radiologists, physiotherapists, strength coaches and coaching staff.

Management and agents often have a say too. Right or wrong is a different story.

Different professionals. Different perspectives. Potentially different messages.

Perhaps this framework provides us with a common lens through which to communicate and collaborate around the individual.

Because codesign isn't simply about getting the patient involved.

It's also about everyone involved understanding the plan.

​Same investor. Multiple collaborative advisors. One (dynamic) plan.