Structure–function relationships of entheses in relation to mechanical load and exercise

Entheses are regions of high‐stress concentration that are commonly affected by overuse injuries in sport. This review summarizes current knowledge of their structure–function relationships – at the macroscopic, microscopic and molecular levels. Consideration is given to how stress concentration is reduced at fibrocartilaginous entheses by various adaptations which ensure that stress is dissipated away from the hard–soft tissue interface. The fundamental question of how a tendon or ligament is anchored to bone is addressed – particularly in relation to the paucity of compact bone at fibrocartilaginous entheses. The concept of an “enthesis organ” is reviewed – i.e. the idea of a collection of tissues adjacent to the enthesis itself, which jointly serve a common function – stress dissipation. The archetypal enthesis organ is that of the Achilles tendon and the functional importance of its subtendinous bursa, with its fibrocartilaginous walls and protruding fat pad, is emphasized. The distribution of adipose tissue elsewhere at entheses is also explained and possible functions of insertion‐site fat are evaluated. Finally, a brief consideration is given to enthesopathies, with attention drawn to the possibility of degenerative changes affecting other regions of an enthesis organ, besides the enthesis itself.