Abstract / Summary
The lymphatic system may influence tendon repair through interstitial transport, immune coordination and lymphatic endothelial cell-derived signalling, but tendon-specific evidence remains limited. This structured critical narrative review searched PubMed/MEDLINE, Embase and Web of Science Core Collection from inception to 20 August 2026, supplemented by semantic and citation-based searching. Evidence was synthesised narratively with attention to its directness, anatomical and temporal context, study design and outcome. Available anatomical evidence places tendon lymphatics mainly in superficial and peritendinous compartments. After injury, lymphatic remodelling and phase-dependent changes in tracer-defined clearance have been observed, but increased vessel abundance does not establish improved transport or better healing. Current evidence suggests two mechanistically distinct axes. The transport-dependent axis encompasses interstitial clearance and drainage to regional lymph nodes, although its contribution to immune regulation and repair remains unproven. The lymphoangiocrine axis has stronger causal support: lymphatic endothelial cell-derived Reelin regulates tendon stem/progenitor cell maintenance, tenogenic differentiation and regeneration in preclinical models. Studies of tendon–bone healing and heterotopic ossification further indicate that lymphatic effects vary with anatomical context, molecular target and disease stage. Proposed interventions remain investigational. The lymphatic system is biologically relevant to tendon repair but is not yet a validated therapeutic target. Tendon-specific causal studies must distinguish lymphatic structure, transport and secretory activity and determine their spatial, temporal and functional relationships with repair outcomes.