BACKGROUND:Tendon pathology on imaging has been associated with an increased risk of developing symptoms. This evidence is based on classifying the tendon as normal or pathological. It is unclear whether the extent of tendon pathology is associated with the development or severity of symptoms. OBJECTIVES:To investigate whether the presence and extent of tendon pathology on ultrasound tissue characterisation (UTC), or a previous history of symptoms, were associated with the development of symptoms over a football season. METHODS:179 male Australian football players underwent UTC imaging of their Achilles and/or patellar tendon at the start of the pre-season. Players completed monthly OSTRC overuse questionnaires to quantify the presence and severity of Achilles and/or patellar tendon symptoms. Risk factor analysis was performed to identify associations between imaging and the development of symptoms. RESULTS:A pathological Achilles tendon increased the risk of developing symptoms (RR=3.2, 95%CI 1.7-5.9). Conversely, a pathological patellar tendon was not significantly associated with the development of symptoms (RR=1.8, 95%CI 0.9-3.7). Quantification of tendon structure using UTC did not enhance the ability to identify athletes who developed symptoms. Previous history of symptoms was the strongest predictor for the development of symptoms (Achilles RR=3.0 95%CI 1.8-4.8; patellar RR=3.7 95%CI 2.2-6.1). CONCLUSION:Tendon pathology was associated with the development of self-reported symptoms; however previous history of symptoms was a stronger risk factor. The extent of disorganisation quantified by UTC should not be used as a marker for the presence or severity of current and future symptoms.