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The latest Ostomy & Wound Management has the full text of this available: A Patient-Centered Approach to Treatment of Morbid Obesity and Lower Extremity Complications: An Overview and Case Studies
The prevalence of morbid obesity, along with related comorbidities, is dramatically increasing in the US, confounding wound care for persons at heightened risk for skin compromise. The purpose of this overview is to examine common concerns related to morbid obesity and interrelated lower extremity complications, including wound and skin infections, dermatologic conditions, lymphovenous obstruction syndromes, chronic venous insufficiency, and anatomical abnormalities such as massive localized lymphedema. Treatment may include surgery for massive lymphedema localizations, compression bandaging for chronic venous insufficiency as well as lymphedema, manual lymph drainage for lymphedema, and prompt and aggressive management of wound infection and bioburden. Case studies are presented to illustrate some lower extremity complications of morbid obesity and appropriate protocols of care. Although increasing evidence suggests that morbidly obese patients are predisposed to secondary lymphedema and that primary lymphedema can cause adult-onset obesity, the mechanisms by which these events occur remain unclear. However, unless the underlying problem of morbid obesity is addressed, the problems for which these patients seek care will continue to recur.
OBJECTIVES: The clinical severity of venous disease is often worse in obese patients. The objectives of this study were to compare lower limb venous physiology assessed by air plethysmography in a large group of obese and normal-weight patients; to consider the effect of posture on these measures and on foot vein pressure in a smaller cohort.
METHODS: Venous function was assessed using air plethysmography and duplex scanning in 934 consecutive patients presenting for assessment of venous disease. These were grouped into obese or non-obese categories. A smaller group of twenty patients with a range of body weights were randomly selected from a database of patients with varicose veins. Foot vein pressures and femoral vein diameter were measured standing, sitting, lying and ambulating.
RESULTS: Venous disease was more clinically severe in the obese limbs (CEAP C5&6 non-obese group 20.5%, obese group 35.4%, p<0.001 chi(2)). Venous reflux was worse in the obese but measures of muscle pump function were better. Residual volumes and fractions were better in the obese (mean residual volume, non-obese 60 SD 36, obese 50 SD 42, p<0.001 t test). In the smaller study group weight correlated with the diameter of the superficial femoral vein (r=0.50), ambulatory venous pressure (r=0.45), venous filling index (r=0.49) and the ejection volume (r=0.38, p<0.05). The foot venous pressure was significantly greater in the obese in all positions.
CONCLUSION: The CEAP clinical stage of venous disease is more advanced in obese patients than non-obese patients with comparable anatomical patterns of venous incompetence. This may be the result of raised intra-abdominal pressure reported in previous studies, leading to greater reflux, increased vein diameter and venous pressures.
Temporal parameters of the foot roll-over during walking: Influence of obesity and sarcopenic obesity on postmenopausal women.
Monteiro MA, Gabriel RC, Sousa MF, Castro MN, Moreira MH. Maturitas. 2010 Jul 16. [Epub ahead of print]
OBJECTIVES: The purpose of this study was to establish a reference dataset for temporal parameters on postmenopausal women during walking and to explore the effect of obesity and sarcopenic obesity on the same parameters.
METHODS: Based on plantar pressure data collected from 239 postmenopausal women, the initial contact, final contact, time to peak pressure and the duration of contact at the 10 anatomical areas of the foot considered were measured. Body composition was evaluated by octopolar bioimpedance.
RESULTS: Non-obese and non-sarcopenic started with heel contact followed by a latero-medial contact of the metatarsals and finally the hallux (the sarcopenic obese group ended in the toes 2-5). After heel off, the forefoot started to push off at the lateral metatarsals, followed by a more central push off and finally over the hallux (the sarcopenic obese group presented a greater oscillation in the metatarsals). The stance phase was divided into four distinct phases: initial contact (22.30%), forefoot contact (19.98%), foot flat (13.40%) and forefoot push off (44.32%). Sarcopenic obese spent more time in the forefoot contact phase (relative and absolute) and less time in the initial contact phase (%).
CONCLUSIONS: These findings provide a reliable and representative reference dataset for temporal characteristics of foot roll-over during walking of postmenopausal women. Sarcopenic obesity affects significantly the temporal characteristics of foot roll-over during walking in this population. Such findings are of concern to clinicians interested in the promotion of activity to reduce obesity and gain or maintain muscle, since sarcopenic obesity affects normal walking, which might increase injuries
Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery.
Vincent HK, Ben-David K, Conrad BP, Lamb KM, Seay AN, Vincent KR. Surg Obes Relat Dis. 2012 Jan 16.
Joint pain is a common musculoskeletal complaint of morbidly obese patients that can result in gait abnormalities, perceived mobility limitations, and declining quality of life (QOL). It is not yet known whether weight loss 3 months after bariatric surgery can induce favorable changes in joint pain, gait, perceived mobility, and QOL. Our objectives were to examine whether participants who had undergone bariatric surgery (n = 25; laparoscopic Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding) demonstrate improvements in joint pain, gait (speed, stride/step length, width of base of support, toe angles, single/double support, swing and stance time, functional ambulatory profile), mobility, and QOL by 3 months compared with nonsurgical controls (n = 20). The setting was an orthopedics laboratory at a university hospital in the United States.
The present study was a prospective, comparative study. Numeric pain scales (indicating the presence and severity of pain), mobility-related surveys, and the Medical Outcomes Study short-form 36-item questionnaire (SF-36) were completed, and gait and walking speed were assessed at baseline and at month 3.
The bariatric group lost an average of 21.6 ± 7.7 kg. Significant differences existed between the 2 groups at month 3 in step length, heel to heel base of support, and the percentage of time spent in single and double support during the gait cycle (all P <.05). The severity of low back pain and knee pain decreased by 54% and 34%, respectively, with no changes in the control group (P = .05). The walking speed increased by 15% in the bariatric group (108-123 cm/s; P <.05) but not in the control group. Compared with the control group, fewer bariatric patients perceived limitations with walking and stair climbing by month 3. The bariatric group had a 4.8-cm increase in step length, 2.6% increase in single support time during the gait cycle, and 2.5-cm reduction in the base of support (all P <.05). The SF-36 physical component scores increased 11.8 points in the bariatric group compared with the control group, which showed no improvement by month 3 (P <.0001).
Improvements in some, but not all, gait parameters, walking speed, and QOL and of perceived functional limitations occur by 3 months after a bariatric procedure.
The effects of obesity on the balance and gait parameters like step width and foot angle (degree of toe out) in young adults were studied. 60 subjects of both the genders were taken. 30 were taken as a control group (non-obese, BMI < 25) and 30 were taken as experimental group (obese, BMI 30 >). Functional Reach Test (FRT) was used for Balance Testing and the Footprint method was used for Gait parameters measurements. The value of functional reach test in females was 11.90 +/- 0.12 inches in control group and 7.01 +/- 1.80 inches in experimental group (t = 5.31, P < 0.001) and in males, it was 16.45 +/- 0.72 inches in control and 11.66 +/- 0.53 inches in experimental group (t = 6.47, P < 0.001). The degree of toe out in females was 6.66 +/- 0.08 degrees for control and 8.13 +/- 0.21 degrees for experimental group (t = 4.08, P < 0.01) and in males, it was 6.59 +/- 0.04 for control and 9.79 +/- 0.51 for experimental group (t = 6.53, P < 0.001). The step width was found to be 4.41 +/- 0.15 inches (control group) and 6.27 +/- 0.35 inches (experimental) in males (t = 4.53, P < 0.01) and it was 3.95 +/- 0.03 inches (control) and 3.42 +/- 1.05 inches (experimental) in females (t = 0.77, P > 0.05). We concluded that obesity has a negative impact on balance of an individual. The degree of toe out was more in obese group as compared to normal BMI group in both genders. The Step Width measurement was more in males of obese group than that in males of normal BMI group but it showed statistically insignificant when compared in females of both groups.
The association between body mass index and musculoskeletal foot disorders: a systematic review.
Butterworth PA, Landorf KB, Smith SE, Menz HB. Obes Rev. 2012 Apr 13.
The primary aim of this systematic review was to investigate the relationship between body mass index (BMI) and foot disorders. The secondary aim was to investigate whether weight loss is effective for reducing foot pain. Five electronic databases (Ovid MEDLINE, Ovid EMBASE, Ovid AMED, CINAHL and The Cochrane Library) and reference lists from relevant papers were searched in April 2011. Twenty-five papers that reported on the association between BMI and musculoskeletal foot disorders met our inclusion criteria and were reviewed. The evidence indicates: (i) a strong association between increased BMI and non-specific foot pain; and (ii) a strong association between increased BMI and chronic plantar heel pain in a non-athletic population. The evidence is inconclusive regarding the relationship between BMI and the following specific disorders of the foot; hallux valgus, tendonitis, osteoarthritis and flat foot. With respect to our second aim, there were only two prospective cohort studies that reported a reduction in foot symptoms following weight loss surgery. In summary, increased BMI is strongly associated with non-specific foot pain in the general population and chronic plantar heel pain in a non-athletic population. However, there is currently limited evidence to support weight loss to reduce foot pain.
The World Health Organization estimates that in 2015 there will be approximately 2.3 billion overweight adults and more than 700 million obese individuals worldwide. Excess weight can lead to several complications, such degenerative diseases.
To estimate the frequency and local of musculoskeletal pain in the lower limbs before and after bariatric surgery.
Cross-sectional descriptive study consisting of 22 obese individuals who filled in questionnaires before and six months after undergoing bariatric surgery. Data were shown through a descriptive analysis. The statistical analysis was performed with significance level at 5%.
Musculoskeletal pain in the lower limbs was placed preoperatively in 87.5% in the ankle and foot, knee 80% and 91.7% in the hip. Postoperative pain remained present in 12.5% in the ankle and foot, knee 20% and 8.3% in the hip, with statistical significance (p <0.001).
Obese people who underwent bariatric surgery experienced a marked reduction in both frequency and intensity of musculoskeletal pain located in order in the hip, ankle and foot, and knee.
On the news this morning- UK based doctors are not allowed to use the word obesity to patients anymore. They have to call them bloaters. Or, something like that.
I find that a simple smile and a "who ate all the pies then fatty?" as the patient walks through the door gets the message across without upsetting anyone.
Tact costs nothing.
David Holland MSc(Bioeng), BSc(Hons) Pod Med.
Expert Witness - Association of Personal Injury Lawyers.
2014 Individual Member - Expert Witness Institute.
I don't see why we need an alternative word for obese? As time goes by the word obese seems to be changing meaning anyway. Now adays it seems to almost represent an idiopathic disease.
I only ever hear obese people saying that they eat next to nothing and I always take people at their word. That being correct we have a situation where the energy output is greater than the energy input. If we can identify the gene, implant it in the starving millions, problem solved.
obesity, by the same token, tiny input of food energy large accumulation of spare energy seems to me to be the first appearance of what might be classified as a homeopathic disease.
keep back it's mine, you heard it here first.OBESITY IS THE FIRST RECOGNISED HOMEOPATHIC DISEASE, ie the smaller the intake of food the greater the accumulation of fat.
Apart from that, energy imput 1 unit output 2 units, the planets saved. Forget wind farms, nuclear power station, etc. The answer to global warming is in front of you.
Are Knee and Foot Orthopedic Problems More Disabling in the Superobese?
Fabris SM, Faintuch J, Brienze SL, Brito GB, Sitta IS, Mendes EL, Fonseca IC, Cecconello I. Obes Surg. 2012 Sep 18.
Aiming to ascertain whether frequency and severity of knee and foot problems were different between morbid obesity (MO) and superobesity (SO), a prospective clinical study was designed.
Bariatric candidates (N = 81, body mass index 40-81.3 kg/m(2), 43.2 % with SO) were submitted to knee and foot radiologic assessment, baropodometric footprint measurement, and the questionnaires Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Foot and Ankle Outcome Score (FAOS). Main outcome measures were imaging diagnosis of knee osteoarthritis and flatfoot, along with functional impact on activities of daily living estimated by the questionnaires.
Knee osteoarthritis was radiologically diagnosed in 74.1 % (60/81), and the entire cohort suffered from flatfoot according to both footprint index and talar-first metatarsal radiographic angle; nevertheless, distribution was not different between SO and MO. However, WOMAC and FAOS scores were markedly worse in SO, affecting joint pain, stiffness, and general mobility. This is the first protocol of our knowledge to address foot and knee derangements in SO.
Functional impairment was more severe in SO, despite a morphologic pattern similar to MO. Even though amelioration is probable with weight loss, long-term orthopedic assistance might be required in such circumstances.
This study aimed to assess the presentation of gait for adults who are overweight, independent of the confounding influence of velocity.
Cross sectional study design. Twenty-five adults of a healthy weight were matched by age, gender, height and velocity to twenty-five adults who were overweight. Participants traversed a 10m walkway embedded with 2 AMTI force platforms (AMTI BP400600 Force Platforms: Advanced Mechanical Technologies, Inc., Watertown, MA, USA) and running between 2 CODA Dual CX1 sensors (CODA CX1: Charnwood Dynamics, Barrow on Soar, Leicestershire, England). Temporal–spatial parameters, maximum ground reaction forces, maximum joint powers, and three dimensional kinematic and kinetic parameters at the 7 events of the gait cycle were assessed.
With velocity accounted for, relatively few changes in the presentation of gait were seen for adults who were overweight. Alterations included increased stance phase duration, hip flexion, knee flexion, hip abduction, and knee varus for overweight adults. A reduction in hip abductor moment normalised for body mass was noted for overweight adults. Absolute maximum ground reaction forces were increased while maximum hip power absorption was reduced for overweight adults.
Changes were seen at the hip and knee during the swing phase of gait. During swing there is a stronger association with soft tissue injury as compared to joint injury. Overweight individuals were seen to adopt few alterations during the stance phase to accommodate for the increased absolute ground reaction forces. As a result the joint surfaces of overweight adults are exposed to increased loading.
Fat mass is a predictor of incident foot pain.
Butterworth PA, Urquhart DM, Cicuttini FM, Menz HB, Strauss BJ, Proietto J, Dixon J, Jones G, Landorf KB, Wluka AE. Obesity (Silver Spring). 2013 Mar 20
Foot pain is a common complaint in adults. Increased body mass index and fat mass have been linked only to foot pain prevalence. Therefore, we conducted a longitudinal study to examine the relationship between body composition and incident foot pain over three years.
DESIGN AND METHODS:
Sixty-one community dwelling participants from a previous study of musculoskeletal health, who did not have foot pain at study inception in 2008, were invited to take part in this follow-up study in 2011. Current foot pain was determined using the Manchester Foot Pain and Disability Index and body composition was measured using dual x-ray absorptiometry at study baseline.
Of the 51 respondents (84% response rate, 37 females and 14 males), there were 11 who developed foot pain. Body mass index ranged from underweight to morbidly obese (17 kg/m2 to 44 kg/m2 ),mean 27.0 kg/m2 ± 6.0. Incident foot pain was positively associated with both fat mass (OR 1.11, 95% CI 1.03 to 1.20) and fat-mass index (OR 1.28, 95% CI 1.04 to 1.57) in multivariate analysis.
Fat mass is a predictor of incident foot pain. This study supports the notion that incident foot pain in overweight individuals is associated with fat mass rather than body mass alone.
Back pain is one of the most common complaints that patients report to physicians and two-thirds of the population has an elevated body mass index (BMI), indicating they are either overweight or obese. It was once assumed that extra body weight would stress the low back and lead to pain, however, researchers have reported inconsistencies association between body weight and back pain. In contrast, more recent studies do indicate that an elevated BMI is associated with back pain and other musculoskeletal pain syndromes due to the presence of a chronic systemic inflammatory state, suggesting that the relationship between BMI and musculoskeletal pains be considered in more detail.
To describe how an elevated BMI can be associated with chronic systemic inflammation and pain expression. To outline measurable risk factors for chronic inflammation that can be used in clinical practice and discuss basic treatment considerations.
Adiposopathy, or "sick fat" syndrome, is a term that refers to an elevated BMI that is associated with a chronic systemic inflammatory state most commonly referred to as the metabolic syndrome. The best available evidence suggests that the presence of adiposopathy determines if an elevated BMI will contribute to musculoskeletal pain expression. It is not uncommon for physicians to fail to identify the presence of adiposopathy/metabolic syndrome.
Patients with an elevated BMI should be further examined to identify inflammatory factors associated with adiposopathy, such as the metabolic syndrome, which may be promoting back pain and other musculoskeletal pain syndromes.
OK! OK! Enough of the downside of obesity what about the upside?
House breakins, muggings, violent crime, in fact almost all crime shows an inverse relationship to bodyweight. The most effective way to reduce crime is to eat more.
The more obese the nation the less the need for the maintenance of public spaces, sports fields, sports centres etc. Just concrete them over and call them car parks or build fast food outlets on them. Think of the reduction in taxes, etc..
That old saying re- maintaining good health of the lower limbs is undoubtedly absolutely true. 'Never run if you can walk. Never walk if you can stand. Never stand if you can sit. Never sit if you can lie down'. Four hundred pounds and above therefore represents the pinnacle of success.
So come on give us some more of the good news of 'Big is bloatiful'.
The ability to estimate body size from the skeleton has broad applications, but is especially important to the forensic community when identifying unknown skeletal remains. This research investigates the utility of using entheses/muscle skeletal markers of the lower limb to estimate body size and to classify individuals into average, obese, and active categories, while using a biomechanical approach to interpret the results. Eighteen muscle attachment sites of the lower limb, known to be involved in the sit-to-stand transition, were scored for robusticity and stress in 105 white males (aged 31-81 years) from the William M. Bass Donated Skeletal Collection. Both logistic regression and log linear models were applied to the data to (1) test the utility of entheses as an indicator of body weight and activity level, and (2) to generate classification percentages that speak to the accuracy of the method. Thirteen robusticity scores differed significantly between the groups, but classification percentages were only slightly greater than chance. However, clear differences could be seen between the average and obese and the average and active groups. Stress scores showed no value in discriminating between groups. These results were interpreted in relation to biomechanical forces at the microscopic and macroscopic levels. Even though robusticity alone is not able to classify individuals well, its significance may show greater value when incorporated into a model that has multiple skeletal indicators. Further research needs to evaluate a larger sample and incorporate several lines of evidence to improve classification rates.
Apparently the most effective method for assessing the previous fat index of a skeleton is known in the trade as the'skid distance'.
As fat begins to degrade it appears to melt and runs off the body. The more fat the further it runs.
As forensic examiners approach the body they start to slip in the molten fat and the distance from the body at which they start to slip and slide is known as the 'skid distance'.
Not a lot of people knows that and the rest don't want to know it.
Effects of obesity on lower extremity muscle function during walking at two speeds
Zachary F. Lerneremail address, Wayne J. Board, Raymond C. Browning Gait & Posture; Article in Press
•We used musculoskeletal models to quantify muscle function in obese adults.
•Kinematic differences exist at certain speeds in obese vs. nonobese adults.
•Differences in the function of certain muscles exist between groups.
•Gait adaptation may be due to abnormal muscle requirements in obese adults.
Walking is a recommended form of physical activity for obese adults, yet the effects of obesity and walking speed on the biomechanics of walking are not well understood. The purpose of this study was to examine joint kinematics, muscle force requirements and individual muscle contributions to the walking ground reaction forces (GRFs) at two speeds (1.25ms−1 and 1.50ms−1) in obese and nonobese adults. Vasti (VAS), gluteus medius (GMED), gastrocnemius (GAST), and soleus (SOL) forces and their contributions to the GRFs were estimated using three-dimensional musculoskeletal models scaled to the anthropometrics of nine obese (35.0 (3.78kgm−2)); body mass index mean (SD)) and 10 nonobese (22.1 (1.02kgm−2)) subjects. The obese individuals walked with a straighter knee in early stance at the faster speed and greater pelvic obliquity during single limb support at both speeds. Absolute force requirements were generally greater in obese vs. nonobese adults, the main exception being VAS, which was similar between groups. At both speeds, lean mass (LM) normalized force output for GMED was greater in the obese group. Obese individuals appear to adopt a gait pattern that reduces VAS force output, especially at speeds greater than their preferred walking velocity. Greater relative GMED force requirements in obese individuals may contribute to altered kinematics and increased risk of musculoskeletal injury/pathology. Our results suggest that obese individuals may have relative weakness of the VAS and hip abductor muscles, specifically GMED, which may act to increase their risk of musculoskeletal injury/pathology during walking, and therefore may benefit from targeted muscle strengthening.
Ankle Pathology in Atraumatic Overweight and Nonoverweight Patients
A Comprehensive MRI Review
Melissa M. Galli, DPM, MHA, AACFAS; Nicole M. Protzman, MS; Eiran M. Mandelker, MD; Amit Malhotra, MD; Edward Schwartz, DPM, FACFAS; Stephen A. Brigido, DPM, FACFAS Foot Ankle Spec July 7, 2014
With the increased prevalence of obesity, there has been a parallel rise in musculoskeletal disorders. However, the effect of body mass index (BMI) on pathology of the hindfoot and ankle is scarcely understood. The purpose of the present report was to compare the number of tendinous and ligamentous pathologies within the hindfoot and ankle between overweight (BMI ≥ 25.00 kg/m2) and nonoverweight (BMI < 25.00 kg/m2) atraumatic patients. We hypothesized that overweight patients would demonstrate more tendinous and ligamentous pathologies compared with their nonoverweight counterparts. Five hundred consecutive magnetic resonance images were reviewed. One hundred eight patients met the inclusion and exclusion criteria. Sixty-six patients were overweight and 42 patients were nonoverweight. Ninety-eight percent of overweight patients demonstrated pathology of a tendinous or ligamentous nature, whereas 62% of nonoverweight patients demonstrated pathology of a tendinous or ligamentous nature. Thus, the prevalence of pathology was 1.59 times higher among overweight patients compared with nonoverweight patients. Moreover, controlling for age, overweight patients demonstrated approximately twice as many tendinous and ligamentous pathologies compared with nonoverweight patients (adjusted mean ± SD = 4.44 ± 2.14 vs 1.98 ± 2.07, respectively), which was statistically significantly different (P < .001). To definitively assess causation and the clinical evolution of hindfoot and ankle pathology, prospective, longitudinal cohort studies are warranted.
Objective: To investigate the relationship between body mass index (BMI) and foot joint pain (FJP) over a 5-year period in a community based cohort.
Methods: We examined a subset of women from the 'Chingford Women's Study', a community cohort followed up for 20 years. From a baseline of 1003 female participants, we reviewed data from 639 (64%) women for whom complete data sets for foot joint pain (FJP) and body mass index (BMI) were obtained over a five year period between years 10 (Y10) and 15 (Y15). Descriptive statistics, binary regression modelling and odds ratios (OR) were used to examine the longitudinal relationship between BMI and FJP.
Results: For Y10 and Y15 the median age was 61 years (57-67) and 66 years (62-72); mean BMI 26.7 kg/m2 (± 4.6) and 27.2 kg/m2 (4.8) respectively. FJP prevalence was 21.6% Y10 and 26.6% Y15. Longitudinal analyses showed that both BMI and FJP increased significantly from Y10 to Y15 (p < 0.001). The odds of having FJP after a 5-year period increased by 4.9% for each BMI unit increase 5 years earlier (OR 1.049, 95% CI 1.011-1.089; p = 0.012). This remained significant when adjusted for age, diabetes and rheumatoid arthritis (OR 1.051, 95% CI 1.011-1.091; p = 0.012).
Conclusion: This is the first large cohort longitudinal study that demonstrates that, in middle aged women, a high BMI precedes and is predictive of FJP independent of age. Evidence from our findings can be used to identify those individuals at risk of developing FJP
Purpose. In the last few years, evidence has emerged to support the possible association between increased BMI and susceptibility to some musculoskeletal diseases. We systematically review the literature to clarify whether obesity is a risk factor for the onset of tendinopathy.
Methods. We searched PubMed, Cochrane Central, and Embase Biomedical databases using the keywords “obesity,” “overweight,” and “body mass index” linked in different combinations with the terms “tendinopathy,” “tendinitis,” “tendinosis,” “rotator cuff,” “epicondylitis,” “wrist,” “patellar,” “quadriceps,” “Achilles,” “Plantar Fascia,” and “tendon.”
Results. Fifteen studies were included. No level I study on this subject was available, and the results provided are ambiguous. However, all the 5 level II studies report the association between obesity measured in terms of BMI and tendon conditions, with OR ranging between 1.9 (95% CI: 1.1–2.2) and 5.6 (1.9–16.6).
Conclusions. The best evidence available to date indicates that obesity is a risk factor for tendinopathy. Nevertheless, further studies should be performed to establish the real strength of the association for each type of tendinopathy, especially because the design of the published studies does not allow identifying a precise cause-effect relationship and the specific role of obesity independently of other metabolic conditions.