Age-related changes in biomechanical properties of the Achilles tendon in rabbits

Sarcopenia: etiology, clinical consequences, intervention, and assessment

The aging process is associated with loss of muscle mass and strength and decline in physical functioning. The term sarcopenia is primarily defined as low level of muscle mass resulting from age-related muscle loss, but its definition is often broadened to include the underlying cellular processes involved in skeletal muscle loss as well as their clinical manifestations. The underlying cellular changes involve weakening of factors promoting muscle anabolism and increased expression of inflammatory factors and other agents which contribute to skeletal muscle catabolism. At the cellular level, these molecular processes are manifested in a loss of muscle fiber cross-sectional area, loss of innervation, and adaptive changes in the proportions of slow and fast motor units in muscle tissue. Ultimately, these alterations translate to bulk changes in muscle mass, strength, and function which lead to reduced physical performance, disability, increased risk of fall-related injury, and, often, frailty. In this review, we summarize current understanding of the mechanisms underlying sarcopenia and age-related changes in muscle tissue morphology and function. We also discuss the resulting long-term outcomes in terms of loss of function, which causes increased risk of musculoskeletal injuries and other morbidities, leading to frailty and loss of independence.

Tuning passive mechanics through differential splicing of titin during skeletal muscle development

During postnatal development, major changes in mechanical properties of skeletal muscle occur. We investigated passive properties of skeletal muscle in mice and rabbits that varied in age from 1 day to approximately 1 year. Neonatal skeletal muscle expressed large titin isoforms directly after birth, followed by a gradual switch toward progressively smaller isoforms that required weeks-to-months to be completed. This suggests an extremely high plasticity of titin splicing during skeletal muscle development. Titin exon microarray analysis showed increased expression of a large group of exons in neonatal muscle, when compared to adult muscle transcripts, with the majority of upregulated exons coding for the elastic proline-glutamate-valine-lysine (PEVK) region of titin. Protein analysis supported expression of a significantly larger PEVK segment in neonatal muscle. In line with these findings, we found >50% lower titin-based passive stiffness of neonatal muscle when compared to adult muscle. Inhibiting 3,5,3'-tri-iodo-L-thyronine and 3,5,3',5'-tetra-iodo-L-thyronine secretion did not alter isoform switching, suggesting no major role for thyroid hormones in regulating differential titin splicing during postnatal development. In summary, our work shows that stiffening of skeletal muscle during postnatal development occurs through a decrease in titin isoform size, due mainly to a marked restructuring of the PEVK region of titin.

Implantation increases tensile strength and collagen content of self-assembled tendon constructs

Tissue-engineered tendons, derived from an autologous cell source, have the potential to provide an ideal replacement graft that is biologically compatible and has the ability to adapt to the specific mechanical requirements of the in vivo environment. Scaffold-free tendon constructs have been successfully engineered in vitro. However, when compared against native tendons the constructs demonstrate both a lower tensile strength and collagen content. We hypothesized that the in vitro environment lacks certain environmental stimuli and that implantation in vivo would facilitate the maturation of engineered tissues. Using primary Achilles tendon fibroblasts from adult rats, self-organizing constructs were created in vitro. Tendon constructs were implanted subcutaneously into the groins of adult rats for 4 wk, while controls remained in vitro. Implanted constructs increased in stiffness by three orders of magnitude when compared with the in vitro controls (7,500 vs. 22.3 kPa). This increase in tangent modulus correlated with a significant increase in collagen content, as measured by hydroxyproline concentration, from 3.9% for the in vitro controls to 22.7% in the in vivo conditioned group. In addition, collagen fiber diameter increased from 22.0 to 75.4 nm as a result of in vivo implantation. The tensile strength and collagen content of in vivo conditioned constructs were similar to the values determined for neonatal rat tibialis anterior tendons.

Mechanical properties of the patellar tendon in adults and children

It is not currently known how the mechanical properties of human tendons change with maturation in the two sexes. To address this, the stiffness and Young's modulus of the patellar tendon were measured in men, women, boys and girls (each group, n=10). Patellar tendon force (F(pt)) was calculated from the measured joint moment during a ramped voluntary isometric knee extension contraction, the antagonist knee extensor muscle co-activation quantified from its electromyographical activity, and the patellar tendon moment arm measured from magnetic resonance images. Tendon elongation was imaged using the sagittal-plane ultrasound scans throughout the contraction. Tendon cross-sectional area was measured at rest from ultrasound scans in the transverse plane. Maximal F(pt) and tendon elongation were (mean+/-SE) 5453+/-307 N and 5+/-0.5 mm for men, 3877+/-307 N and 4.9+/-0.6 mm for women, 2017+/-170 N and 6.2+/-0.5 mm for boys and 2169+/-182 N and 5.9+/-0.7 mm for girls. In all groups, tendon stiffness and Young's modulus were examined at the level that corresponded to the maximal 30% of the weakest participant's F(pt) and stress, respectively; these were 925-1321 N and 11.5-16.5 MPa, respectively. Stiffness was 94% greater in men than boys and 84% greater in women than girls (p<0.01), with no differences between men and women, or boys and girls (men 1076+/-87 N/mm; women 1030+/-139 N/mm; boys 555+/-71 N/mm and girls 561.5+/-57.4 N/mm). Young's modulus was 99% greater in men than boys (p<0.01), and 66% greater in women than girls (p<0.05). There were no differences in modulus between men and women, or boys and girls (men 597+/-49 MPa; women 549+/-70 MPa; boys 255+/-42 MPa and girls 302+/-33 MPa). These findings indicate that the mechanical stiffness of tendon increases with maturation due to an increased Young's modulus and, in females due to a greater increase in tendon cross-sectional area than tendon length.

Response of tibialis anterior tendon to a chronic exposure of stretch-shortening cycles: age effects

BACKGROUND

The purpose of the current study was to investigate the effects of aging on tendon response to repetitive exposures of stretch-shortening cycles (SSC's).

METHODS

The left hind limb from young (3 mo, N = 4) and old (30 mo, N = 9) male Fisher 344 x Brown Norway rats were exposed to 80 maximal SSCs (60 deg/s, 50 deg range of motion) 3 x/week for 4.5 weeks in vivo. After the last exposure, tendons from the tibialis anterior muscle were isolated, stored at -80 degrees C, and then tested using a micro-mechanical testing machine. Deformation of each tendon was evaluated using both relative grip-to-grip displacements and reference marks via a video system.

RESULTS

At failure, the young control tendons had higher strain magnitude than the young exposed (p < 0.01) and the old control tendons (p < .0001). Total load at inflection was affected by age only (p < 0.01). Old exposed and control tendons exhibited significantly higher loads at the inflection point than their young counterparts (p < 0.05 for both comparisons). At failure, the old exposed tendons carried higher loads than the young exposed tendons (p < 0.05). Stiffness was affected by age only at failure where the old tendons exhibited higher stiffness in both exposed and control tendons than their young counterparts (p < 0.05 and p < 0.01, respectively).

CONCLUSION

The chronic protocol enhanced the elastic stiffness of young tendon and the loads in both the young and old tendons. The old exposed tendons were found to exhibit higher load capacity than their younger counterparts, which differed from our initial hypothesis.

Simulation of biological growth

Researchers concerned with the growth of biological tissue often use models that predict the growth as a function of a mechanical stimulus such as stress, strain or elastic energy. However, a general theory for bulk growth should consider that the mechanical stimulus may only be one of many factors contributing to growth. Another important factor could be time, as living tissues can be assumed to have a pre-programmed directional biological growth that is independent of mechanical stimuli. This paper has two objectives: the first is to introduce the concept of directional biological growth within a well developed growth theory, the second is to present the computational methods by which three-dimensional growth that encompasses time and stress effects can be simulated using commercially available finite element analysis software.

Ageing of human muscles and tendons

At whole muscle level, the reduction in intrinsic force observed with ageing is probably the result of the combined effect of changes in: (i) muscle architecture, (ii) tendon mechanical properties, (iii) neural drive (reduced agonist and increased antagonist muscles' activity), and (iv) single fibre specific tension. Only recently have alterations in muscle architecture and in tendon mechanical properties been shown to contribute to the reduction in intrinsic muscle force, and tendon stiffness changes play an important role. Of note is the fact that most of these changes may be reversed by 14 weeks of resistive training, for both fibre fascicle length and tendon stiffness were found to be increased by 10% and 64%, respectively. Surprisingly, however, training had no effect on the estimated relative length-tension properties of the muscle, indicating that the effects of increased tendon stiffness and increased fascicle length cancelled out each other. It seems that natural strategies may be in place to ensure that the relative operating range of muscle remains unaltered by changes in physical activity, and perhaps age.

Ageing changes in the tensile properties of tendons: influence of collagen fibril volume fraction

Connective tissues are biological composites comprising of collagen fibrils embedded in (and reinforcing) the hydrated proteoglycan-rich (PG) gel within the extracellular matrices (ECMs). Age-related changes to the mechanical properties of tissues are often associated with changes to the structure of the ECM, namely, fibril diameter. However, quantitative attempts to correlate fibril diameter to mechanical properties have yielded inconclusive evidence. Here, we described a novel approach that was based on the rule of mixtures for fiber composites to evaluate the dependence of age-related changes in tendon tensile strength (sigma) and stiffness (E) on the collagen fibril cross-sectional area fraction (rho), which is related to the fibril volume fraction. Tail tendons from C57BL6 mice from age groups 1.6-35.3 months old were stretched to failure to determine sigma and E. Parallel measurements of rho as a function of age were made using transmission electron microscopy. Mathematical models (rule of mixtures) of fibrils reinforcing a PG gel in tendons were used to investigate the influence of rho on ageing changes in sigma and E. The magnitudes of sigma, E, and rho increased rapidly from 1.6 months to 4.0 months (P-values <0.05) before reaching a constant (age independent) from 4.0 months to 29.0 months (P-values >0.05); this trend continued for E and rho (P-values >0.05) from 29.0 months to 35.3 months, but not for sigma, which decreased gradually (P-values <0.05). Linear regression analysis revealed that age-related changes in sigma and E correlated positively to rho (P-values <0.05). Collagen fibril cross-sectional area fraction rho is a significant predictor of ageing changes in sigma and E in the tail tendons of C57BL6 mice.

Static and dynamic biomechanical properties of the regenerating rabbit Achilles tendon

BACKGROUND

Since tendons show viscoelastic behavior, dynamic viscoelastic properties should be assessed in addition to static biomechanical properties. We evaluated differences between static and dynamic biomechanical properties of the regenerating rabbit Achilles tendon following tenotomy.

METHODS

At 3, 6, or 12 weeks after right Achilles tenotomy, the right (regenerating) and left (control) tendons were collected with the calcaneus from 49 rabbits. A unidirectional failure test and a dynamic viscoelastic test were conducted.

FINDINGS

Tensile strength and Young's modulus (static biomechanical properties) in the regenerating group at Week 6 were significantly greater than at Week 3, while at Week 12, these were significantly greater than at Week 6. However, even at Week 12, both parameters were less than in the control group. The value of tan delta represents dynamic viscoelasticity, a smaller tan delta indicates greater elasticity. tan delta for the regenerating group was significantly greater than for the control group at Week 3, but regenerating and control groups did not significantly differ at Week 6. No marked change was seen from Weeks 6 to 12 in the regenerating group, and no significant difference in tan delta was evident between the regenerating and control groups at Week 12.

INTERPRETATION

Dynamic biomechanical properties of regenerating rabbit Achilles tendons may improve more rapidly than static biomechanical properties. Ability to tolerate dynamic movement in the healing Achilles tendon may improve more rapidly than ability to withstand static stresses.

Region specific patellar tendon hypertrophy in humans following resistance training

AIM

To examine if cross-sectional area (CSA) differs along the length of the human patellar tendon (PT), and if there is PT hypertrophy in response to resistance training.

METHODS

Twelve healthy young men underwent baseline and post-training assessments. Maximal isometric knee extension strength (MVC) was determined unilaterally in both legs. PT CSA was measured at the proximal-, mid- and distal PT level and quadriceps muscle CSA was measured at mid-thigh level using magnetic resonance imaging. Mechanical properties of the patellar tendons were determined using ultrasonography. Subsequently, subjects performed 12 weeks of heavy resistance knee extension training with one leg (Heavy-leg), and light resistance knee extension training with the other leg (Light-leg).

RESULTS

The MVC increased for heavy-leg (15 +/- 4%, P < 0.05), but not for light-leg (6 +/- 4%). Quadriceps CSA increased in heavy-legs (6 +/- 1%, P < 0.05) while unchanged in light-legs. Proximal PT CSA (104 +/- 4 mm(2)) was smaller than the mid-tendon CSA (118 +/- 3 mm(2)), which again was smaller than distal tendon CSA (127 +/- 2 mm(2), P < 0.05). Light-leg PT CSA increased by 7 +/- 3% (P < 0.05) at the proximal tendon level, but was otherwise unchanged. Heavy-leg PT CSA increased at the proximal and distal tendon levels by 6 +/- 3% and 4 +/- 2% respectively (P < 0.05), but was unchanged at the mid tendon level. PT stiffness increased in heavy-legs (P < 0.05) but was unchanged in light-legs. Modulus remained unchanged in both legs.

CONCLUSIONS

To our knowledge, this study is the first to report tendon hypertrophy following resistance training. Further, the data show that the human PT CSA varies along the length of the tendon.

Aging enhances a mechanically-induced reduction in tendon strength by an active process involving matrix metalloproteinase activity

Age-associated and degenerative loss of functional integrity in soft tissues develops from effects of cumulative and subtle changes in their extracellular matrix (ECM). The highly ordered tendon ECM provides the tissue with its tensile strength during loading. As age and exercise collide in the high incidence of tendinopathies, we hypothesized that aged tendons fail due to cumulative damage resulting from a combination of diminished matrix repair and fragmentation of ECM proteins induced by prolonged cyclical loading, and that this is an active cell-mediated process. We developed an equine tendon explant model to examine the effect of age on the influence of prolonged cyclical loading at physiologically relevant strain rates (5% strain, 1 Hz for 24 h) on tissue mechanical properties, loss of ECM protein and matrix metalloproteinase (MMP) expression. We show significantly diminished mechanical strength of cyclically loaded tissue compared to controls (39.7 +/- 12%, P <or= 0.05) this reduction was dependent on the presence of both viable cells and metalloproteinase activity. Furthermore, tendon from older specimens was more susceptible to weakening (11-30 years, 50%P <or= 0.05) compared to immature and young mature tissue (1-3 years, 34%; 4-10 years, 35%, respectively). Cyclical load also induced release of degraded cartilage oligomeric matrix protein, an integral ECM protein, an effect that could be mimicked by culture with fibronectin fragments. These findings indicate prolonged cyclical loading of physiological magnitude decreases tendon tensile strength by an active process, and that MMPs may contribute to loss of functional competence, exaggerated by age, via load-induced proteolytic disruption of the ECM.

Stretching for prevention of Achilles tendon injuries: a review of the literature

Professional and recreational athletes commonly perform pre-exercise stretching to prevent musculoskeletal injuries. Little definitive evidence exists that clearly demonstrates the efficacy of stretching in reducing injury. Achilles tendon injuries are among the most common injuries affecting active individuals in the United States today. Clinicians commonly recommend stretching the Achilles tendon without concrete scientific evidence to support such a claim. Few studies have addressed the effect of stretching in Achilles tendon injuries, and it is unclear if the conclusions made for musculoskeletal injuries can be applied to the Achilles tendon. Biomechanical studies of the Achilles tendon and measurements of the tendon's reflex activity have demonstrated possible mechanisms for the potential benefit of stretching, including load-induced hypertrophy and increased tendon tensile strength. Recent prospective studies have contended that reductions in plantarflexor strength and increases in ankle dorsiflexion range of motion from stretching the Achilles tendon may increase the risk of injury. Studies examining stretching in injury prevention, the biomechanical properties of injuries to the Achilles tendon were compiled and reviewed. Although many theories have been published regarding the potential benefits and limitations of stretching, few studies have been able to definitively demonstrate its utility in injury prevention.

Mechanical properties of the triceps surae tendon and aponeurosis in relation to intensity of sport activity

The purpose of the present study was to investigate whether the mechanical properties (i.e. force strain relationship) of the triceps surae tendon and aponeurosis relate to the performed sport activity in an intensity-dependent manner. This was done by comparing sprinters with endurance runners and subjects not active in sports. Sixty-six young male subjects (26+/-5 yr; 183+/-6 cm; 77.6+/-6.7 kg) participated in the study. Ten of these subjects were adults not active in sports, 28 were endurance runners and 28 sprinters. All subjects performed isometric maximal voluntary plantar flexion contractions (MVC) on a dynamometer. The distal aponeuroses of the gastrocnemius medialis (GM) was visualised by ultrasound during the MVC. The results showed that only the sprinters had higher normalised stiffness (relationship between tendon force and tendon strain) of the triceps surae tendon and aponeurosis and maximal calculated tendon forces than the endurance runners and the subjects not active in sports. Furthermore, including the data of all 66 examined participants tendon stiffness correlated significantly (r=0.817, P<0.001) with the maximal tendon force achieved during the MVC. It has been concluded that the mechanical properties of the triceps surae tendon and aponeurosis do not show a graded response to the intensity of the performed sport activity but rather remain at control level in a wide range of applied strains and that strain amplitude and/or frequency should exceed a given threshold in order to trigger additional adaptation effects. The results further indicate that subjects with higher muscle strength possibly increase the margin of tolerated mechanical loading of the tendon due to the greater stiffness of their triceps surae tendon and aponeurosis.

Adaptability of elderly human muscles and tendons to increased loading

Senile sarcopenia, the loss of muscle mass associated with aging, is one of the main causes of muscle weakness and reduced locomotor ability in old age. Although this condition is mainly driven by neuropathic processes, nutritional, hormonal and immunological factors, as well as a reduction in physical activity, contribute to this phenomenon. Sarcopenia alone, however, does not fully account for the observed muscle weakness, as the loss of force is greater than that accounted for by the decrease in muscle size. As a consequence, a reduction in the force per unit area, both at single fibre and at whole muscle level, is observed. We recently suggested that at whole muscle level, this reduction in intrinsic force is the result of the combined effect of changes in (1) muscle architecture, (2) tendon mechanical properties, (3) neural drive (reduced agonist and increased antagonist muscle activity) and (4) single fibre-specific tension. Whereas several studies support the role of the last two factors in the loss of intrinsic muscle force with aging, alterations in muscle architecture and in tendon mechanical properties have also been shown to contribute to the above phenomenon. Indeed, sarcopenia of the human plantarflexors, represented by a 25% reduction in muscle volume, was found to be associated with a 10% reduction in fibre fascicle length and 13% reduction in pennation angle. These architectural alterations were accompanied by a 10% decrease in tendon stiffness, attributable to alterations in tendon material properties, as suggested by a 14% decrease in Young's modulus. Most of these changes may be reversed by 14 weeks of resistive training; both fibre fascicle length and tendon stiffness were found to be increased by 10 and 64%, respectively. Surprisingly, however, training had no effect on the estimated relative length-tension properties of the muscle, indicating that the effects of greater tendon stiffness and increased fascicle length cancelled out each other. It seems that natural strategies may be in place to ensure that the relative operating range of muscle remains unaltered by changes in physical activity, in old age.

Myotendinous alterations and effects of resistive loading in old age

The loss of muscle mass associated with ageing only partly explains the observed decline in muscle strength. This paper provides evidence of the contribution of muscular, tendinous and neural alterations to muscle weakness in old age and discusses the complex interplay between the changes of the contractile tissue with those of the tendinous tissue in relation to the mechanical behavior of the muscle as a whole. Despite the considerable structural and functional alterations, the elderly musculoskeletal system displays remarkable adaptability to training in old age and many of these adverse effects may be substantially mitigated, if not reversed, by resistive loading. The interplay between these muscular and tendinous adaptations has an impact both on the length-force and force-velocity relationships of the muscle and is likely to affect the range of motion, rate of force development, maximum force development and speed of movement of the older individual.

Myotendinous plasticity to ageing and resistance exercise in humans

The age-related loss of muscle mass known as senile sarcopenia is one of the main determinants of frailty in old age. Molecular, cellular, nutritional and hormonal mechanisms are at the basis of sarcopenia and are responsible for a progressive deterioration in skeletal muscle size and function. Both at single-fibre and at whole-muscle level, the loss of force exceeds that predicted by the decrease in muscle size. For single fibres, the loss of intrinsic force is mostly due to a loss in myofibrillar protein content. For whole muscle, in addition to changes in neural drive, alterations in muscle architecture and in tendon mechanical properties, exemplified by a reduction in tendon stiffness, have recently been shown to contribute to this phenomenon. Resistance training can, however, cause substantial gains in muscle mass and strength and provides a protective effect against several of the cellular and molecular changes associated with muscle wasting and weakness. In old age, not only muscles but also tendons are highly responsive to training, since an increase in tendon stiffness has been observed after a period of increased loading. Many of the myotendinous factors characterizing ageing can be at least partly reversed by resistance training.

Calf muscle-tendon properties and postural balance in old age

We tested the hypothesis that compromised postural balance in older subjects is associated with changes in calf muscle-tendon physiological and mechanical properties. Trial duration and center of pressure (COP) displacements were measured in 24 younger (aged 24+/-1 yr), 10 middle-aged (aged 46+/-1 yr), and 36 older (aged 68+/-1 yr) healthy subjects under varying levels of postural difficulty. Muscle-tendon characteristics were assessed by dynamometry, twitch superimposition, and ultrasonography. In tandem and single-leg stances, trial duration decreased (<or=65% lower, P<0.001) and COP displacements increased (<or=90% higher, P<0.05) with age. Muscle strength, size, activation capacity, and tendon mechanical properties decreased with age by 55, 13, 13, and 36-48%, respectively (P<0.05). Regressions with these parameters and balance indexes were significant (P<0.05) for single-leg and tandem (0.69<r2<0.90) postures only, indicating that the age-related changes in muscle-tendon characteristics may explain the majority of the variance in balance performance during tasks more difficult than habitual bipedal stance.

Cruciate ligament laxity and femoral intercondylar notch narrowing in early-stage knee osteoarthritis

OBJECTIVE

The influence of the cruciate ligaments in spontaneous osteoarthritis (OA) is not understood, although ligament rupture is known to cause secondary OA. Additionally, femoral notch narrowing at the anterior cruciate ligament (ACL) insertion site is associated with disease severity, but it is unknown whether ligament deterioration precedes or follows osteophyte formation. We examined cruciate ligament mechanics and metabolism and the intercondylar notch width in OA-prone Dunkin-Hartley (DH) guinea pigs at ages up to and including the age at OA onset (24 weeks), and compared the data with those in age-matched controls (Bristol strain 2 [BS2] guinea pigs).

METHODS

Guinea pigs were assessed at 3, 6, 9, 12, 16, 20, 24, and 36 weeks of age. ACLs were mechanically tested, and the intercondylar notch width index (NWI) was determined. Cruciate ligament metabolism was determined by measuring the following markers of collagen turnover: matrix metalloproteinase 2 (MMP-2), tissue inhibitor of metalloproteinases 2, C-terminal type I procollagen propeptide (PICP), and the immature collagen-derived crosslink dihydroxylysinonorleucine (DHLNL).

RESULTS

DH guinea pigs had significantly laxer ACLs than did BS2 guinea pigs, at 12, 16, and 24 weeks. We observed elevated levels of pro and active MMP-2, PICP, and DHLNL in the cruciate ligaments of DH animals at most ages, compared with BS2 guinea pigs. The NWI in DH animals was significantly lower than that in BS2 guinea pigs at 24 and 36 weeks.

CONCLUSION

In DH guinea pigs, laxer ACLs, which are associated with increased collagen turnover, may cause joint instability and predispose these animals to the early onset of OA. Decreased intercondylar notch width in the DH animals indicates that bone remodeling at the ACL insertion site is a response to elevated ACL laxity.

Geometric and elastic properties of in vivo human Achilles tendon in young adults

The purpose of this study was to clarify whether the major determinant of the extendibility of the Achilles tendon in young adults was the geometric properties of the tendon. The subjects were 38 healthy young adults (26 male, 12 female; 26 +/- 5 years). The subjects developed maximum voluntary isometric plantar flexion (MVIP) torque while the displacement of the distal myotendinous junction of the medial gastrocnemius and ankle joint rotation was determined using a B-mode ultrasonograph and a goniometer, respectively. The tendon force (F) was calculated from MVIP torque and the moment arm of Achilles tendon. The elongation of the Achilles tendon (delta X) was obtained from the tendon displacements and ankle joint rotation. Achilles tendon stiffness (k) was calculated by dividing F by delta X. The specific stiffness of the Achilles tendon (k(s)) was obtained from k normalized to the Achilles tendon length at rest. The cross-sectional area of the Achilles tendon (CSA) was measured at 5, 10, and 15% of the lower leg length proximal to the insertion of the Achilles tendon using a B-mode ultrasonography. The results showed that more distal portion of the Achilles tendon had a larger CSA, and that there was a strong correlation between the average and minimum Achilles tendon CSA. delta X was 9.9 +/- 2.5 mm. k and k(s) were 330 +/- 77 N/mm and 63 +/- 20 kN, respectively. No significant correlation was seen between CSA and k(s) (r = 0.15, p > 0.05). It was suggested that a stiffer Achilles tendon did not necessarily have a thicker shape, which might indicate that the major determinant of the extendibility of the Achilles tendon was not its geometric properties in young adults.

Effects of age on the repair ability of mesenchymal stem cells in rabbit tendon

Successful tissue engineered repair in the aging adult requires an abundant source of autologous, multipotent mesenchymal stem cells (MSCs). Although the number of bone marrow-derived MSCs declines dramatically with aging, their effectiveness in repair with increasing age has not been studied. We tested the hypothesis that MSCs harvested from geriatric rabbits would not repair patellar tendon defects as well as MSCs harvested from younger adult rabbits. In a novel within-subjects experiment, autologous MSCs were isolated from 1-year old rabbits, culture expanded, and cryogenically preserved. After housing the rabbits for 3 years, MSCs were re-harvested from the 4-year old rabbits and expanded. Five hundred thousand thawed and fresh MSCs were each separately mixed with type I collagen gel (333.3 x 10(3) cells/mg collagen) 24 h before surgery, and the resulting constructs implanted in bilateral full-length central third tendon defects. Twelve weeks post-surgery, the bone-tendon repair-bone units were failed in tension. Intra-animal (paired) comparisons between repair tissue treated with 1-year old MSCs and repair tissue treated with 4-year old MSCs resulted in no significant differences (alpha=0.05) in material properties including maximum stress (10.8 MPa vs. 9.9 MPa; p=0.762), modulus (139.8 MPa vs. 146.2 MPa; p=0.914), and strain energy density (0.52 N mm/mm(3) vs. 0.53 N mm/mm(3); p=0.966). Despite an age-related trend, there were also no significant differences in structural properties including maximum force (62.9 N vs. 27.0 N; p=0.070), stiffness (24.9 N/mm vs. 12.0 N/mm; p=0.111), and strain energy (87.2 N mm vs. 31.4 N mm; p=0.061). A subset of the rabbits (n=4 1 yrMSC, n=2 4 yrMSC) showed the presence of ectopic bone in the repair region and were not included in the mechanical analyses. We conclude that in the rabbit model MSCs do not lose their benefit as a tendon repair therapy with aging and that MSCs can be cryogenically stored for 3 years and still effectively repair soft tissue injuries.

Adaptive response of human tendon to paralysis

To gain insight into the adaptive response of human tendon to paralysis, we compared the mechanical properties of the in vivo patellar tendon in six men who were spinal cord-injured (SCI) and eight age-matched, able-bodied men. Measurements were taken by combining dynamometry, electrical stimulation, and ultrasonography. Tendon stiffness and Young's modulus, calculated from force-elongation and stress-strain curves, respectively, were lower by 77% (P < 0.01) and 59% (P < 0.05) in the SCI than able-bodied subjects. The cross-sectional area (CSA) of the tendon was 17% smaller (P < 0.05) in the SCI subjects, but there was no difference in tendon length between the two groups. Our results indicate that paralysis causes substantial deterioration of the structural and material properties of tendon. This needs to be taken into consideration in the design of electrical stimulation protocols for rehabilitation and experimental purposes, and when interpreting changes in the contractile speed of paralyzed muscle.

Etiologic and pathogenetic factors for rotator cuff tendinopathy

Etiologic and pathogenetic factors for rotator cuff tendinopathy, although often compartmentalized to intrinsic or extrinsic causes, have multifactorial roots. The development of animal models for the study of rotator cuff disease has increased the fund of knowledge regarding this disease and has paved the way for future studies. Further multidisciplinary studies at molecular, biomechanical, and clinical levels should be undertaken to enhance the understanding of this common disorder. Ultimately, the goals of improved care, increased comprehension, and prevention of rotator cuff tendinopathy are attainable.

A computational model for the adaptation of muscle and tendon length to average muscle length and minimum tendon strain

This paper hypothesizes that average muscle length and minimum tendon strain govern muscle and tendon length adaptation in all situations. A model has been implemented to test this hypothesis, and simulations have been performed for normal development, bone lengthening, immobilization, and retinacular release experiments in young and adult animals. The simulation results predict that both muscle and tendon lengthen during normal development, with the rate of tendon growth slowing faster than the rate of muscle growth. The results also predict that muscle length increases during bone lengthening in both young and adult animals, while tendon length increases only in young animals. For immobilization in adult animals, the results predict that muscle length increases when the muscle is immobilized in a lengthened position and decreases when the muscle is immobilized in a shortened position with no change in tendon length. For immobilization in young animals, the results predict reduced muscle growth and increased tendon growth regardless of immobilization position. Finally, the simulations predict that retinacular release which increases excursion of the musculotendinous unit leads to increased muscle length with decreased tendon length in young animals and decreased muscle length with no change in tendon length in adult animals. These simulation results are consistent with experimental findings reported in the literature by other investigators. This suggests that average muscle length and minimum tendon strain may represent general principles that govern muscle and tendon length adaptation.

Evaluation of musculotendinous stiffness in prepubertal children and adults, taking into account muscle activity

Musculotendinous (MT) stiffness of the triceps surae (TS) muscle group was quantified in 28 prepubertal children (7-10 yr) by using quick-release movements at different levels of submaximal contractions. Surface electromyograms (EMG) of each part of the TS and of the tibialis anterior were also recorded. A stiffness index, defined as the slope of the angular stiffness-torque relationship (SIMT-Torque), was used to quantify changes in MT stiffness with age. Results showed a significant decrease in SIMT-Torque with age, ranging from 4.02 +/- 0.29 to 2.88 +/- 0.31 rad-1 for the youngest to the oldest children. Because an increase in stiffness with age was expected due to the maturation of elastic tissues, overactivation of the TS was suspected to contribute to the higher SIMT-Torque values found in the youngest children. TS EMG-torque analyses confirmed that neuromuscular efficiency was significantly lower for the 7- or 8-yr-old children compared with 10-yr-old children, notably due to a higher degree of tibialis anterior coactivation found in the youngest children. Thus the stiffness index originally defined as the slope of the angular stiffness-EMG relationship increased significantly with age toward adult values. The results underlined the necessity to take into account the capacities of muscle activation to quantify changes in elastic properties of muscles, when those capacities are suspected to be altered.

Increased cross-sectional area and reduced tensile stress of the Achilles tendon in elderly compared with young women

The Achilles tendon cross-sectional area (CSA), tensile force, and stress during an isometric contraction were examined in healthy young (n = 9, age = 29 +/- 1 years, mean +/- SEM) and elderly (n = 10, 79 +/- 2 years) women. CSA area was obtained with magnetic resonance imaging 3 cm proximal to the insertion, and tendon force was obtained from the isometric ankle moment. The moment of force about the ankle joint was greater in young women (95 +/- 17 N m) than in elderly women (51 +/- 5 N m; p <.05). The Achilles tendon CSA was significantly greater in elderly women (56.3 +/- 3.0 mm(2)) than in young women (46.0 +/- 1.9 mm(2); p <.01). These data show that young women can exert a greater force than elderly women on the Achilles tendon during voluntary contraction, although elderly women have an increased (22%) tendon CSA, and a lower tendon force than young women. The greater tendon size combines to lower the stress on the tendon markedly, which may reduce the risk of injury to the tendon.

Adjustment of muscle mechanics model parameters to simulate dynamic contractions in older adults

The generation of muscle-actuated simulations that accurately represent the movement of old adults requires a model that accounts for changes in muscle properties that occur with aging. An objective of this study was to adjust the parameters of Hill-type musculo-tendon models to reflect nominal age-related changes in muscle mechanics that have been reported in the literature. A second objective was to determine whether using the parametric adjustments resulted in simulated dynamic ankle torque behavior similar to that seen in healthy old adults. The primary parameter adjustment involved decreasing maximum isometric muscle forces to account for the loss of muscle mass and specific strength with age. A review of the literature suggested the need for other modest adjustments that account for prolonged muscular deactivation, a reduction in maximum contraction velocity, greater passive muscle stiffness and increased normalized force capacity during lengthening contractions. With age-related changes incorporated, a musculo-tendon model was used to simulate isometric and isokinetic contractions of ankle plantarflexor and dorsiflexor muscles. The model predicted that ankle plantarflexion power output during 120 deg/s shortening contractions would be over 40% lower in old adults compared to healthy young adults. These power losses with age exceed the 30% loss in isometric strength assumed in the model but are comparable to 39-44% reductions in ankle power outputs measured in healthy old adults of approximately 70 years of age. Thus, accounting for age-related changes in muscle properties, other than decreased maximum isometric force, may be particularly important when simulating movements that require substantial power development.

A potential mechanism for age-related declines in patellar tendon biomechanics

Injuries to soft tissues such as tendons are becoming ever more frequent among the elderly. While increasing levels of activity likely contribute to these injuries, age-related declines in tendon strength may also be important. Whether these declines in biomechanical properties are associated with changes in fibril diameter or collagen type remains in question. In this study, age-related changes were investigated in patellar tendons from young adult rabbits (1-year old, n = 17) and from rabbits at the onset of senescence (4-year old, n = 33). Patellar tendon biomechanics was correlated with both collagen fibril diameter and with the presence of type V collagen, a known regulator of collagen fibril diameter. We hypothesize that (a) aging from I to 4 years results in significant reductions in patellar tendon biomechanical properties, and (b) these age-related declines are associated with smaller fibril diameters and with the presence of type V collagen. Maximum stress declined 25% between I and 4 years of age (100.7 +/- 5.6 MPa and 74.3 +/- 3.4 MPa, respectively, p < 0.0003) (mean +/- SEM) and strain energy density declined 40% (p < 0.001). The distribution of collagen fibrils from 4-year old rabbits was skewed significantly towards smaller diameters compared to fibrils from 1-year old rabbits (p < 0.001). Type V collagen was observed only in the 4-year old rabbit tendons. These correlations suggest that with increasing age after skeletal maturity, type V collagen may help to regulate the assembly and thus diameter of collagen fibrils and thereby adversely affect patellar tendon strength.

Load-displacement properties of the human triceps surae aponeurosis and tendon in runners and non-runners

The load-displacement and stress-strain characteristics of the human triceps surae tendon and aponeurosis, in vivo, was examined during graded maximal voluntary plantarflexion efforts in runners who trained 80 km/ week or more and age-matched non-runners. Synchronous real-time ultrasonography of triceps surae tendon and aponeurosis displacement, electromyography of the gastrocnemius, soleus and dorsiflexor muscles, and joint angular rotation were obtained. Tendon cross-sectional area and ankle joint moment arm were obtained from magnetic resonance imaging. Tensile tendon force was calculated from the joint moments and tendon moment arm and stress was obtained by dividing force by cross-sectional area. Strain was obtained from the displacements normalized to tendon length. Antagonist coactivation and small amounts of ankle joint rotation significantly affected tensile tendon force and aponeurosis and tendon displacement, respectively (P < 0.01). Plantarflexion moment was similar in runners (138 +/- 27 Nm, mean +/- SEM) and non-runners (142 +/- 17 Nm). Tendon moment arm was alike in non-runner (58.3 +/- 0.2 mm) and runners (55.1 +/- 0.1 mm). Similarly, there was no difference in tendon tensile force between runners (2633 +/- 465 N) and non-runners (2556 +/- 401 N). The cross-sectional area of the Achilles tendon was larger in runners (95 +/- 3 mm2) than non-runners (73 +/- 3 mm(2)) (P < 0.01). The load-deformation data yielded similar stiffness (runners 306 +/- 61 N/mm, non-runners 319 +/- 42 N/mm). The maximal strain and stress was 4.9 +/- 0.8% and 38.2 +/- 9.8 MPa in non-runners and 4.1 +/- 0.8% and 26.3 +/- 5.1 MPa in runners. The larger tendon cross-sectional area in trained runners suggests that chronic exposure to repetitive loading has resulted in a tissue adaptation.

Response of rabbit Achilles tendon to chronic repetitive loading

The objective of this work was to assess the response of tendon to chronic repetitive loading. Controlled muscle stimulation was used to load the rabbit Achilles tendon at a frequency of 1.25 Hz for two hours per day, three days per week for a period of 11 weeks. Average peak tendon force was 26 N during the protocol. The loading protocol did not modify the gross morphology of the tissue, nor its water content or cellularity. Increases in mRNA expression of collagen Type III and MMPs were observed, but no signs of injury were detected by histologic examination of tendon and paratenon structures. The lack of a detectable injury response suggests that the tendons were not loaded beyond their capacity for repair. Factors additional to mechanical loading such as aging, illness or stress may be necessary to produce pathology.

The influence of cross-sectional area on the tensile properties of flexor tendons

Clinicians have long noted substantial variation in the cross-sectional size of flexor tendons in the hand; however, data indicating that surgical repair techniques of lacerated flexor tendons should be altered according to size are unavailable. Our objectives were to evaluate the cross-sectional size differences among tendons within the same hand and to correlate tendon size with tensile mechanical properties after suture repair. Fifty human cadaver flexor digitorum profundus tendons were measured with digital calipers to determine radioulnar and volardorsal diameters. Twenty tendons were used to measure resistance to suture pull-through; tendons were transected at the A2 pulley, and a transverse double-stranded 4-0 Supramid suture (S. Jackson, Inc, Alexandria, VA) was passed through the radioulnar plane of the tendon 1 cm from the transection site. The remaining tendons were transected and repaired by using a modified Kessler repair with double-stranded 4-0 Supramid suture. Both tendon repairs and tendon-suture pull-through specimens were tested to failure in tension by using a material testing machine. Dorsovolar tendon height and tendon cross-sectional area varied significantly between digits, with an average difference of approximately 40% between the values of the smallest (fifth) and largest (third) fingers. Yield and ultimate force determined by pull-through tests of the simple transverse suture correlated positively with tendon radioulnar width. Tensile properties of tendons repaired with a double-stranded modified Kessler repair, however, did not depend significantly on tendon size. These results indicate that the strength of the commonly used Kessler suture technique is not dependent on tendon cross-sectional size within the clinically relevant range of tendons evaluated.

Influence of bone mineral density, age, and strain rate on the failure mode of human Achilles tendons

OBJECTIVE

To examine the influence of strain rate, bone mineral density, and age in determining the mode by which human Achilles tendons fail.

DESIGN

Dual-energy X-ray absorptiometry and mechanical testing of excised Achilles tendon-calcaneus specimens.

BACKGROUND

The Achilles tendon can fail by tendon rupture or bony avulsion. These injuries are caused by similar loading mechanisms and can present similar symptoms. It is important to understand when each mode of injury is likely to occur so that accurate diagnoses can be made and appropriate treatments selected.

METHODS

Excised human Achilles tendons were loaded to failure at strain rates of 1% s(-1) and 10% s(-1) following dual-energy X-ray absorptiometry examination to determine bone mineral density near the tendon insertion. Calcaneal bone mineral density, donor age, and strain rate were compared between specimens that failed by avulsion and those that failed by tendon rupture.

RESULTS

While strain rate was not observed to affect failure mode, the calcaneal bone mineral density of specimens that failed by avulsion was significantly lower than the bone mineral density of specimens that failed by tendon rupture (P=0.004). There was a significant decrease in bone mineral density with age (P=0.004), and the difference in age between the avulsed and ruptured specimens was close to statistical significance (P=0.058). For the avulsed specimens, there was a significant linear relationship between failure load and bone mineral density squared (P=0.002). Logistic regression indicated that the effect of age on failure mode is secondary to the primary effect of bone mineral density.

CONCLUSIONS

The avulsions were primarily "premature" failures associated with low bone mineral density. Since bone mineral density decreases with age, older individuals are more likely to experience avulsions while younger individuals are more likely to experience tendon ruptures.

Mechanical properties of the human achilles tendon

OBJECTIVE

To determine whether the human Achilles tendon has higher material properties than other tendons and to test for strain rate sensitivity of the tendon.

DESIGN

Mechanical testing of excised tendons.

BACKGROUND

While the human Achilles tendon appears to experience higher in vivo stresses than other tendons, it is not known how the Achilles tendon's material properties compare with the properties of other tendons.

METHODS

Modulus, failure stress, and failure strain were measured for excised human Achilles tendons loaded at strain rates of 1% s(-1) and 10% s(-1). Paired t-tests were used to examine strain rate effects, and average properties from grouped data were used to compare the Achilles tendon's properties with properties reported in the literature for other tendons.

RESULTS

Failure stress and failure strain were higher at the faster strain rate, but no significant difference in modulus was observed. At the 1% s(-1)rate, the mean modulus and failure stress were 816 MPa (SD, 218) and 71 MPa (SD, 17), respectively. The failure strain was 12.8% (SD, 1.7) for the bone-tendon complex and 7.5% (SD, 1.1) for the tendon substance. At the 10% s(-1) rate, the mean modulus and failure stress were 822 MPa (SD, 211) and 86 MPa (SD, 24), respectively. The mean failure strain was 16.1% (SD, 3.6) for the bone-tendon complex and 9.9% (SD, 1.9) for the tendon substance. These properties fall within the range of properties reported in the literature for other tendons.

CONCLUSIONS

The material properties of the human Achilles tendon measured in this study are similar to the properties of other tendons reported in the literature despite higher stresses imposed on the Achilles tendon in vivo.

Light microscopic histology of achilles tendon ruptures. A comparison with unruptured tendons

We studied biopsies from the Achilles tendons of patients undergoing open repair for a subcutaneous rupture of their Achilles tendons (27 men, 11 women; mean age, 45.3 +/- 13.8 years) and specimens of Achilles tendons from persons with no known tendon ailments (43 men, 3 women; mean age, 64.2 +/- 9.7 years). Histologic examination was performed using stained slides that were interpreted using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, hyalinization, and glycosaminoglycan. We gave up to three marks for each of these variables, with 0 being normal and 3 being maximally abnormal. All the histology slides were assessed twice in a blinded manner; the agreement between two readings ranged from 0.56 to 0.87 (kappa statistics). The score of ruptured tendons was significantly greater than the average score of control tendons (20.5 +/- 3.6 versus 6.5 +/- 2.1), and there was significantly higher degeneration in the ruptured tendons. Nonruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations. Using these staining techniques, light microscopic degeneration is not a feature of tendons from healthy, older persons.

The development of fatigue quality in high- and low-stressed tendons of sheep (Ovis aries)

The time taken to rupture in cyclic fatigue tests, to a stress of 45 MPa, was used to compare the fatigue quality of tendons from sheep of varying ages. Muscle and tendon cross-sectional areas were used to calculate the stress-in-life of each tendon. For any given age, high-stressed plantaris tendons were of a higher fatigue quality than low-stressed extensor tendons. Both fatigue quality and stress-in-life increased with age for each tendon type. High-stressed tendons are subjected to large increases in stress-in-life during growth, and fatigue quality increased significantly with this stress. This relationship was not seen, however, in low-stressed tendons, which are not subjected to a comparable range of stresses over time. It is possible that cells modify tendon fatigue quality in response to tendon loading history. Whilst Young's modulus was seen to increase with age, no difference was detected between high- and low-stressed tendons.

Changes in ADC caused by tensile loading of rabbit achilles tendon: evidence for water transport

Water diffusion measurements were performed on rabbit Achilles tendons during static tensile loading and tendons in an unloaded state. The apparent diffusion coefficient (ADC) was measured along two directions: parallel and perpendicular to the long axis of the tendon. Tendons were studied after being prepared in two ways: (a) after being stored frozen in phosphate-buffered saline (PBS) and (b) freshly isolated. Statistically significant directional anisotropy was observed in the ADC in all tendons. The ADC was significantly greater in the direction parallel to the long axis of the tendon than in the perpendicular direction. The anisotropy is attributed to the greater restrictions seen by the water molecules in the perpendicular direction and is consistent with the known geometry of the tendon. Storage in PBS caused tendons to swell. This increased the ADC measured along both directions and reduced the anisotropy. The existence of anisotropy in the ADC was not related to the orientation of the specimen in the magnet. The ADC increased along both directions following the application of a 5-N tensile load; the increase was greatest along the perpendicular axis of the tendon. In order to determine whether load-related changes in the ADC reflected changes in interfibrilar spacing, we used electron microscopy to measure load-related changes in fibril spacing. Load-related changes in fiber spacing could not account for the observed changes in the ADC. The increase in ADC caused by loading was attributed to the extrusion of tendon water into a bulk phase along the outside surface of the tendon. In PBS-stored samples, enough fluid was extruded that it could be visualized. The transient response of the ADC to a 5-N tensile load was also studied. The absolute ADC in both directions increased with loading and recovered to baseline upon unloading. The transient changes in ADC, for both loading and unloading, had a mean time constant of approximately 15 min. The magnitude of the load-induced transient ADC changes was comparable to that seen in the static-loading experiments.

Fatigue quality of mammalian tendons

When excised tendons are subjected to a prolonged load, whether constant or oscillatory, fatigue damage accumulates, leading eventually to rupture. ‘Fatigue quality’, assessed by the time-to-rupture under a given stress, was found to vary hugely among the tendons of a wallaby hind limb. This material property correlates with the varied stresses to which tendons from different anatomical sites are exposed in life. The correlation was demonstrated by subjecting each excised tendon to a load equal to the maximum isometric force that its muscle could have developed. The time-to-rupture was then approximately the same for each tendon, on average 4.2 h. A model is introduced in which damage is proposed as the trigger for adaptation of fatigue quality. The model aims, in particular, to explain why low-stressed tendons are not made of a ‘better’ material, although this clearly exists since it is used in high-stressed tendons. The principle of design to a minimum quality is viable in biology because of the availability of self-repair to balance routine damage. Clinical symptoms, to be included under the general heading of ‘overuse injuries’, will only arise when this balance fails.

A model for loading-dependent growth, development, and adaptation of tendons and ligaments

The geometric and material properties of tendons and ligaments change during growth and development. While some of the changes occur in the absence of mechanical loading, normal development requires the mechanical stimulus provided by normal physical activity. We have developed an analytical framework for quantitatively describing changes in uniaxial tendon and ligament properties throughout ontogeny. In our approach, cross-sectional area, modulus, and strength undergo baseline levels of development due to inherent time-dependent biological influences. The properties also change in response to mechanobiological influences by adapting to maintain a constant daily strain stimulus under changing load conditions. We have implemented a computer algorithm based on these concepts and obtained results consistent with experimental observations of normal tendon and ligament growth and development reported by other investigators. Additional results suggest that these concepts can also explain tendon and ligament adaptation to increased or decreased loading experienced during development.