Supplemental Digital Content 2
Table 1. Main characteristics of case-control studies included in this review Author Patient
demographics Percentage of patients with obesity (BMI >
30 kg/m2)
Tissue
involved Outcome Main findings
Wendelboe et al. [60]
n = 1244 Mean age: not reported
Sex: not reported
Not reported RC Association between increased BMI and development and treatment of tendinopathy
Both men (OR 1.86; p = 0.028) and women (OR 2.43; p = 0.002) with higher BMI were more likely to undergo RC-related surgery than those with normal BMIs. This finding was present among patients with lower BMIs as well as those with BMI > 35 kg/m2.
Gumina et al. [29]
n = 601
Mean age: 65.38 years ± 8 years Sex: M 282; F 319
73% with BMI
> 25 kg/m2
RC Association between increased BMI and development of tear and tear size
A positive relationship between obesity and presence of RC was observed (OR 2.49; p = 0.037 in male participants; OR 2.31; p = 0.07 in female participants).
Abate et al.
[5]
n = 76
Mean age 69.6 ± 3.3 years
Sex: M 64; F 12
Not reported Achilles tendon
Association between increased BMI, Type II diabetes, exercise, and the development of Achilles
tendinopathy
Patients showed an increased prevalence of diabetes (42% versus 13.1%; p = 0.004), practice of sports (60.5% versus 28.9%; p < 0.001), and higher BMI values (26.8 ± 3 kg/m2 versus 24.8 ± 2.3 kg/m2; p = 0.001).
Djerbi et al.
[19] n = 306
Mean age 57.8 years (study participants); 59.4 years (controls) Sex: not reported
Not reported RC Association between increased BMI and development of tear and tear size
In a multivariate analysis, the only two factors that had a significant effect on the prevalence of RC tears were smoking and dyslipidemia (OR 4.920 [95% CI 2.046 to 11.834]; p = 0.0004).
Noback et
al. [40] n = 279
Mean age: not reported
Sex: M 246; F 33
Not reported Achilles
tendon Association between increased BMI and exercise and
development of ruptures
There was no clinically important difference in BMI between patients with ruptures and the BMI of controls. Patients who sustained ruptures were also more likely to be active at baseline than those who did not have ruptures.
Abate and Salini [3]
n = 64
Mean age: 39.3 ± 12.9 years
Sex: M 40; F 24
9.3% Achilles
tendon
Association between exercise and mid- portion Achilles tendinopathy
Participants with less-evident, positive effects of running on metabolism were more likely to have mid-portion Achilles tendinopathy.
Participants with mid-portion Achilles tendinopathy had a worse metabolic profile.
Titchener et al. [55]
n = 10,000
Mean age: 55 years Sex: M 4734; F 5266
15.2% RC Association between
increased BMI and development of RC disease
Patients with RC disease had a higher BMI than those in the control group (median BMI 26.5 kg/m2 versus 25.9 kg/m2; p < 0.0001). There was a higher incidence of RC disease among patients with a BMI between 25.1 kg/m2 and 30 kg/m2 (OR 1.23) and between 30.1 kg/m2 and 40 kg/m2 (OR 1.25).
Klein et al.
[34]
n = 944
Mean age: 51.2 ±
Not reported Achilles tendon
Association between increased BMI and
There was an association between obesity and Achilles tendonitis for patients with BMI 25.0-
13.5 years
Sex: M 490; F 454 development and
treatment of Achilles tendonitis
29.9 kg/m2 (OR 2.60; p < 0.01), BMI 30.0-34.9 kg/m2 (OR 3.81; p < 0.01); BMI 35.0-39.9 kg/m2 (OR 3.77; p < 0.01); and BMI > 40 kg/m2 (OR 0.63; p < 0.01).
RC = rotator cuff; HBP = high blood pressure.
Table 2. Main characteristics of cohort studies included in this review Author Type of
study
Patient demographics
Percentage of patients with obesity (BMI > 30 kg/m2)
Tissue involved
Outcome Mean
follow- up duration
Main findings
Ahmad and Jones [9]
Retrospectiv e
n = 76
Mean age: 40 years
Sex: M 61; F 15
42.1% Achilles tendon
Functional score, pain, surgical complications
49.4 months
Obese patients were more likely to develop postoperative wound complications than nonobese patients (OR 1.979; p = 0.01).
There was no difference in mean postoperative functional and pain scores between non-obese
population and obese one.
Ateschrang et al. [11]
Retrospectiv e
n = 146
Mean age: 59 ± 9.1 years
Sex: not reported
21.3% RC Functional
scores, pain, RC integrity
43 months
On clinical examination, obese patients had worse DASH scores.
On clinical examination, obese patients had worse DASH scores (mean value 86% non-obese, 81% obese; p = 0.0468) and worse Constant-Murley score (mean value 80 pre-
obese/normal, 70 obese, p = 0.007)
Obese patients were more likely to undergo re-tear compared with non-obese and pre-obese patients (OR 4.3; p = 0.0086).
Hillam et al. [31]
Retrospectiv e
n = 2126 Mean age: non- obese: 42.6 ± 13.9 years;
obese: 46.7 ± 12.8 years Sex: M 1615; F 511
41.7% Achilles tendon
Surgical complications
30 days There was no difference between obese and non-obese patients in the development of surgery complications (OR = 1.5628; p = 0.1).
Kessler et al. [33]
Retrospectiv e
n = 213 Mean age:
58.08 ± 9.24 years
Sex: M 134; F 79
40.0% RC Functional
scores, pain, surgical complications
3 years At the 3-year follow-up interval, there were no difference in American Shoulder and Elbow Surgeons score, VAS of pain scores or Western Ontario
Rotator Cuff score between obese and nonobese subjects (WORC mean value 713.0 versus 696.1; p
= 0.718; ASES mean value 70.4 versus 72.2; p = 0.407; VAS mean value 28.38 versus 28.25; p
= 0.954).
There was no difference in the incidence of postoperative complications between obese and non-obese patients (OR 0.9886; p
= 0.92).
Burrus et Retrospectiv n = 18,948 15.6% Achilles Outcome after Not At 90 days after primary Achilles
al. [15] e Mean age: not reported
Sex: M 12,084;
F 6864
F 1900; M
1062 tendon surgery reported tendon repair, obese patients were more likely to develop
postoperative wound complications (OR 2.1; p <
0.001), infections (OR 1.8; p <
0.001), venous thromboembolism events (OR 1.8; p < 0.001), and medical complications (OR 3.9; p
< 0.001) and to have a lower risk of ankle stiffness (OR 0.4; p <
0.001).
Rechardt et al. [46]
Prospective n = 163 Mean age: 45 years
Sex: M 22; F 141
14% Upper
extremity soft tissues
Association between adipokines and recovery from upper extremity soft-tissue disorders
2 weeks 8 weeks 12 weeks
Obese patients were more likely to report lower rate of resolution of the condition than non-obese patients (OR 0.6 [95% CI 0.4 to 1.8]).
Higher levels of resistin (OR 1.58 [95% CI 1.18 to 2.11]) and visfatin (OR 1.29 [95% CI 0.94 to 1.78]) at baseline predicted a higher rate of resolution of the condition at 8 weeks, while higher levels of leptin predicted a lower rate of recovery at 8 weeks (OR 0.73 [95% CI 0.51 to 1.02]).
RC = rotator cuff; PT = patellar tendon.
Table 3. Main characteristics of cross-sectional studies included in this review Author Patient demographics Percentage of
patients with obesity (BMI >
30 kg/m^2)
Tissue involved
Outcome Main findings
Holmes and Lin [32]
n = 82
Mean age: 50.5 years Sex: M 38; F 44
59.7% Achilles
tendon Association between increased BMI and development of tendinopathy
Obesity correlated with diminution of local micro-vascularity.
Obesity was associated with Achilles tendinopathy.
Frey and Zamora [24]
n = 1411 Mean age: not reported
Sex: not reported
52% with BMI >
25 kg/m2 Ankle and
foot tendons Association between increased BMI and development
Patients overweight or obese are more likely to develop tendinitis in general by 1.9 times.
Plantar fasciitis was diagnosed 1.4 times more often in obese patients than in non- obese patients.
Comparing BMI and osteoarthritis, the study revealed that obese patients were 1.5 times more likely to have a diagnosis of osteoarthritis than non-obese patients.
Labovitz et al. [36]
n = 105
Mean age: not reported
Sex: not reported
46.66% Plantar fascia Association between increased BMI and development
Patients with BMI > 30 kg/m2 were approximately 2.4 times more likely to experience plantar fasciitis than those with a BMI < 30 kg/m2 (p = 0.04).
Patients with hamstring tightness were approximately 8.7 times more likely to experience plantar fasciitis (p < 0.001).
Fairley et
al. [21] n = 297
Mean age: 57.6 years (no tendinopathy); 59 years (tendinopathy) Sex: M 111; F 186
Not reported Quadriceps
tendon Association between obesity and
tendinopathy
Participants with patellar tendinopathy had greater body weight (OR 1.04; p < 0.001) and BMI (OR 1.1; p = 0.001) than those without patellar tendinopathy.
Weight at the age of 18 to 21 years and heaviest lifetime weight were also greater
for those with tendinopathy than for those without (OR 1.04; p < 0.001).
Patellar tendinopathy was common in community-based adults and was associated with current and past obesity assessed by BMI or body weight, but not fat mass (OR 1.02 [95% CI 0.99 to 1.05]; p
= 0.21).
Shiri et al.
[50]
n = 4783
Mean age: 46.3 ± 9.6 years
Sex: M 47.5%;
F 52.5%
Not reported Epicondylitis Association between increased BMI and development
BMI and waist and hip circumference were strongly associated with medial
epicondylitis but not with lateral epicondylitis (association statistically relevant only for women).
Rechardt et al. [45]
n = 6237
Mean age: 50.8 years (males); 52.9 years (females)
Sex: M 2850; F 3387
15.77% RC Association between
increased BMI and development
Weight-related factors, especially abdominal obesity, were associated with shoulder pain in both men and women.
Abdominal obesity was also associated with chronic RC tendinitis.
RC = rotator cuff.
Table 4. Main characteristics of case series included in this review Author Patients
Demographics
Percentage of patients with obesity (BMI >
30 kg/m2)
Tissue involved
Outcome Mean
follow-up duration
Main findings
Reb et
al. [44] n = 6879 Mean age: 54 years
Sex: not reported
Not reported TPT, PF,
or both Association between higher BMI and risk of tendinopathy
Not
reported There was no difference in the mean BMI between any two groups.
Galli et al. [28]
n = 108
Mean age: 41.9 years
Sex: M 37; F 71
61% with BMI
> 25 kg/m2
Ankle and foot tendons
Association between higher BMI and risk of tendinopathy
Not reported
Overweight patients have twice as many tendinous and ligamentous pathologies as non- overweight patients (adjusted mean ± SD = 4.44
± 2.14 versus 1.98 ± 2.07; p < 0.001). Moreover, there was a positive association between BMI and tendinous or ligamentous pathology (rpb = 0.41; p
< 0.001) and between BMI and total tendinous pathology (r = 0.43; p < 0.001).
TPT = tibialis posterior tendon; PF = plantar fascia.