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Kwan KYC, Ng KWK, Rao Y, Zhu C, Qi S, Tuan RS, Ker DFE, Wang DM. Effect of Aging on Tendon Biology, Biomechanics and Implications for Treatment Approaches. Int J Mol Sci 2023; 24:15183. [PMID: 37894875 PMCID: PMC10607611 DOI: 10.3390/ijms242015183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/07/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
Tendon aging is associated with an increasing prevalence of tendon injuries and/or chronic tendon diseases, such as tendinopathy, which affects approximately 25% of the adult population. Aged tendons are often characterized by a reduction in the number and functionality of tendon stem/progenitor cells (TSPCs), fragmented or disorganized collagen bundles, and an increased deposition of glycosaminoglycans (GAGs), leading to pain, inflammation, and impaired mobility. Although the exact pathology is unknown, overuse and microtrauma from aging are thought to be major causative factors. Due to the hypovascular and hypocellular nature of the tendon microenvironment, healing of aged tendons and related injuries is difficult using current pain/inflammation and surgical management techniques. Therefore, there is a need for novel therapies, specifically cellular therapy such as cell rejuvenation, due to the decreased regenerative capacity during aging. To augment the therapeutic strategies for treating tendon-aging-associated diseases and injuries, a comprehensive understanding of tendon aging pathology is needed. This review summarizes age-related tendon changes, including cell behaviors, extracellular matrix (ECM) composition, biomechanical properties and healing capacity. Additionally, the impact of conventional treatments (diet, exercise, and surgery) is discussed, and recent advanced strategies (cell rejuvenation) are highlighted to address aged tendon healing. This review underscores the molecular and cellular linkages between aged tendon biomechanical properties and the healing response, and provides an overview of current and novel strategies for treating aged tendons. Understanding the underlying rationale for future basic and translational studies of tendon aging is crucial to the development of advanced therapeutics for tendon regeneration.
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Affiliation(s)
- Ka Yu Carissa Kwan
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; (K.Y.C.K.); (K.W.K.N.); (Y.R.); (C.Z.); (R.S.T.); (D.F.E.K.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ka Wai Kerry Ng
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; (K.Y.C.K.); (K.W.K.N.); (Y.R.); (C.Z.); (R.S.T.); (D.F.E.K.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ying Rao
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; (K.Y.C.K.); (K.W.K.N.); (Y.R.); (C.Z.); (R.S.T.); (D.F.E.K.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chenxian Zhu
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; (K.Y.C.K.); (K.W.K.N.); (Y.R.); (C.Z.); (R.S.T.); (D.F.E.K.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shengcai Qi
- Department of Prosthodontics, Shanghai Stomatological Hospital, Fudan University, Shanghai 200040, China;
| | - Rocky S. Tuan
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; (K.Y.C.K.); (K.W.K.N.); (Y.R.); (C.Z.); (R.S.T.); (D.F.E.K.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Center for Neuromusculoskeletal Restorative Medicine, Hong Kong Science Park, Hong Kong SAR, China
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Dai Fei Elmer Ker
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; (K.Y.C.K.); (K.W.K.N.); (Y.R.); (C.Z.); (R.S.T.); (D.F.E.K.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Center for Neuromusculoskeletal Restorative Medicine, Hong Kong Science Park, Hong Kong SAR, China
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Ministry of Education Key Laboratory for Regenerative Medicine, School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Dan Michelle Wang
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China; (K.Y.C.K.); (K.W.K.N.); (Y.R.); (C.Z.); (R.S.T.); (D.F.E.K.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Center for Neuromusculoskeletal Restorative Medicine, Hong Kong Science Park, Hong Kong SAR, China
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Ministry of Education Key Laboratory for Regenerative Medicine, School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
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Kupka JR, Sagheb K, Al-Nawas B, Schiegnitz E. The Sympathetic Nervous System in Dental Implantology. J Clin Med 2023; 12:jcm12082907. [PMID: 37109243 PMCID: PMC10143978 DOI: 10.3390/jcm12082907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/07/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
The sympathetic nervous system plays a vital role in various regulatory mechanisms. These include the well-known fight-or-flight response but also, for example, the processing of external stressors. In addition to many other tissues, the sympathetic nervous system influences bone metabolism. This effect could be highly relevant concerning osseointegration, which is responsible for the long-term success of dental implants. Accordingly, this review aims to summarize the current literature on this topic and to reveal future research perspectives. One in vitro study showed differences in mRNA expression of adrenoceptors cultured on implant surfaces. In vivo, sympathectomy impaired osseointegration in mice, while electrical stimulation of the sympathetic nerves promoted it. As expected, the beta-blocker propranolol improves histological implant parameters and micro-CT measurements. Overall, the present data are considered heterogeneous. However, the available publications reveal the potential for future research and development in dental implantology, which helps to introduce new therapeutic strategies and identify risk factors for dental implant failure.
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Affiliation(s)
- Johannes Raphael Kupka
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Keyvan Sagheb
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Eik Schiegnitz
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, 55131 Mainz, Germany
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Wasker SVZ, Challoumas D, Weng W, Murrell GAC, Millar NL. Is neurogenic inflammation involved in tendinopathy? A systematic review. BMJ Open Sport Exerc Med 2023; 9:e001494. [PMID: 36793930 PMCID: PMC9923261 DOI: 10.1136/bmjsem-2022-001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 02/11/2023] Open
Abstract
Neurogenic pain and inflammation have been hypothesised to play an important role in tendinopathy. This systematic review aimed to present and assess the evidence on neurogenic inflammation in tendinopathy. A systematic search was conducted through multiple databases to identify human case-control studies assessing neurogenic inflammation through the upregulation of relevant cells, receptors, markers and mediators. A newly devised tool was used for the methodological quality assessment of studies. Results were pooled based on the cell/receptor/marker/mediator assessed. A total of 31 case-control studies were eligible for inclusion. The tendinopathic tissue was obtained from Achilles (n=11), patellar (n=8), extensor carpi radialis brevis (n=4), rotator cuff (n=4), distal biceps (n=3) and gluteal (n=1) tendons. Through pooling the results of included studies based on the marker of neurogenic inflammation assessed, we identified possible upregulation of protein gene product 9.5 (PGP 9.5), N-methyl-D-aspartate Receptors, glutamate, glutamate receptors (mGLUT), neuropeptide Y (NPY) and adrenoreceptors in tendinopathic tissue versus control. Calcitonin gene-related peptide (CGRP) was not found to be upregulated, and the evidence was conflicting for several other markers. These findings show the involvement of the glutaminergic and sympathetic nervous systems and the upregulation of nerve ingrowth markers supporting the concept that neurogenic inflammation plays a role in tendinopathy.
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Affiliation(s)
- Shimon Vinay Zedeck Wasker
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Dimitris Challoumas
- School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Wai Weng
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - George A C Murrell
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Neal L Millar
- School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Rajpar I, Tomlinson RE. Function of peripheral nerves in the development and healing of tendon and bone. Semin Cell Dev Biol 2022; 123:48-56. [PMID: 33994302 PMCID: PMC8589913 DOI: 10.1016/j.semcdb.2021.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 01/03/2023]
Abstract
Although the functions of the peripheral nervous system in whole body homeostasis and sensation have been understood for many years, recent investigation has uncovered new roles for innervation in the musculoskeletal system. This review centers on advances regarding the function of nerves in the development and repair of two connected tissues: tendon and bone. Innervation in healthy tendons is generally confined to the tendon sheaths, and tendon-bone attachment units are typically aneural. In contrast to tendon, bone is an innervated and vascularized structure. Historically, the function of abundant peripheral nerves in bone has been limited to pain and some non-painful sensory perception in disease and injury. Indeed, much of our understanding of peripheral nerves in tendons, bones, and entheses is limited to the source and type of innervation in healthy and injured tissues. However, more recent studies have made important observations regarding the appearance, type, and innervation patterns of nerves during embryonic and postnatal development and in response to injury, which suggest a more expansive role for peripheral nerves in the formation of musculoskeletal tissues. Indeed, tendons and bones develop in a close spatiotemporal relationship in the embryonic mesoderm. Models of limb denervation have shed light on the importance of sensory innervation in bone and to a lesser extent, tendon development, and more recent work has unraveled key nerve signaling pathways. Furthermore, loss of sensory innervation also impairs healing of bone fractures and may contribute to chronic tendinopathy. However, more study is required to translate our knowledge of peripheral nerves to therapeutic strategies to combat bone and tendon diseases.
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Affiliation(s)
- Ibtesam Rajpar
- Department of Orthopedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan E Tomlinson
- Department of Orthopedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
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Fahy EJ, Griffin M, Lavin C, Abbas D, Longaker MT, Wan D. The Adrenergic System in Plastic and Reconstructive Surgery: Physiology and Clinical Considerations. Ann Plast Surg 2021; 87:e62-e70. [PMID: 33833152 DOI: 10.1097/sap.0000000000002706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The primary organ systems and tissues concerning plastic and reconstructive surgery include the integument, vasculature, subcutis, and peripheral nerves, because these may individually or collectively be injured requiring reconstruction, or indeed be used in reconstruction themselves through grafts, flaps, or anastomoses. Adrenergic receptors are present throughout these anatomic components on the vasculature, adipose, platelets, immune cells, keratinocytes, melanocytes, fibroblasts, peripheral nerves, and tendons. Herein, the influence of adrenergic signaling on the physiology of anatomic components related to plastic surgery is discussed, along with clinical considerations of this systems involvement in procedures, such as free flap reconstruction, skin grafting, fat grafting, and other areas relevant to plastic and reconstructive surgery. Current evidence as well as potential for further investigation is discussed.
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Affiliation(s)
- Evan J Fahy
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | - Michelle Griffin
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | - Christopher Lavin
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | - Darren Abbas
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
| | | | - Derrick Wan
- From the Division of Plastic Surgery, Department of Surgery, Hagey Laboratory for Pediatric Regenerative Medicine
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Kovanur Sampath K, Mani R, Katare R, Neale J, Cotter J, Tumilty S. Thoracic Spinal Manipulation Effect on Neuroendocrine Response in People With Achilles Tendinopathy: A Randomized Crossover Trial. J Manipulative Physiol Ther 2021; 44:420-431. [PMID: 34376321 DOI: 10.1016/j.jmpt.2021.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/13/2020] [Accepted: 06/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of the present study was to determine the neuroendocrine response after a thoracic spinal manipulation in people with Achilles tendinopathy. METHODS This was a randomized 2-sequence, 2-period crossover trial. A total of 24 participants, mean (standard deviation) age of 48 (7) years, with a diagnosis of Achilles tendinopathy (>3 mo) were randomly assigned into sequence 1 (sham intervention and then thoracic spinal manipulation) or sequence 2 (thoracic spinal manipulation and then sham intervention). The trial was conducted at a university laboratory with a washout period of 1 week. The primary outcome measure was the testosterone/cortisol (T/C) ratio (salivary samples). The secondary outcome measures included heart rate variability (measured with electrocardiography) and total oxygenation index (nmol/L) of calf muscle and Achilles tendon (measured with near-infrared spectroscopy). A 2-way mixed-model analysis of variance was performed. The statistic of interest was the condition by time interaction. RESULTS A statistically significant condition by time interaction was found for the T/C ratio (mean difference: -0.16; confidence interval: -0.33 to 0.006; interaction: P < .05) and the total oxygenation index (mean difference: 1.35; confidence interval: -1.3 to 4.1; interaction: P < .05) of calf muscle but not for Achilles tendon (P = .6); however, no difference was found for heart rate variability (P = .5). CONCLUSION In people with Achilles tendinopathy, thoracic spinal manipulation resulted in immediate increase in the total oxygenation index in the calf muscle followed by an increase in the T/C ratio 6 hours post-intervention.
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Affiliation(s)
- Kesava Kovanur Sampath
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand.
| | - Ramakrishnan Mani
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Rajesh Katare
- Department of Physiology-Heart Otago, University of Otago, Dunedin, New Zealand
| | - Joshua Neale
- Department of Physiology-Heart Otago, University of Otago, Dunedin, New Zealand
| | - James Cotter
- School of Physical Education, Sport and Exercise Science, Dunedin, New Zealand
| | - Steve Tumilty
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Sohn R, Rösch G, Junker M, Meurer A, Zaucke F, Jenei-Lanzl Z. Adrenergic signalling in osteoarthritis. Cell Signal 2021; 82:109948. [PMID: 33571663 DOI: 10.1016/j.cellsig.2021.109948] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/14/2022]
Abstract
Adrenoceptors (ARs) mediate the effects of the sympathetic neurotransmitters norepinephrine (NE) and epinephrine (E) in the human body and play a central role in physiologic and pathologic processes. Therefore, ARs have long been recognized as targets for therapeutic agents, especially in the field of cardiovascular medicine. During the past decades, the contribution of the sympathetic nervous system (SNS) and particularly of its major peripheral catecholamine NE to the pathogenesis of osteoarthritis (OA) attracted growing interest. OA is the most common degenerative joint disorder worldwide and a disease of the whole joint. It is characterized by progressive degradation of articular cartilage, synovial inflammation, osteophyte formation, and subchondral bone sclerosis mostly resulting in chronic pain. The subchondral bone marrow, the periosteum, the synovium, the vascular meniscus and numerous tendons and ligaments are innervated by tyrosine hydroxylase-positive (TH+) sympathetic nerve fibers that release NE into the synovial fluid and cells of all abovementioned joint tissues express at least one out of nine AR subtypes. During the past decades, several in vitro studies explored the AR-mediated effects of NE on different cell types in the joint. So far, only a few studies used animal OA models to investigate the contribution of distinct AR subtypes to OA pathogenesis in vivo. This narrative review shortly summarizes the current background knowledge about ARs and their signalling pathways at first. In the second part, we focus on recent findings in the field of NE-induced AR-mediated signalling in different joint tissues during OA pathogenesis and at the end, we will delineate the potential of targeting the adrenergic signalling for OA prevention or treatment. We used the PubMed bibliographic database to search for keywords such as 'joint' or 'cartilage' or 'synovium' or 'bone' and 'osteoarthritis' and/or 'trauma' and 'sympathetic nerve fibers' and/or 'norepinephrine' and 'adrenergic receptors / adrenoceptors' as well as 'adrenergic therapy'.
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Affiliation(s)
- Rebecca Sohn
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt / Main, Germany
| | - Gundula Rösch
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt / Main, Germany
| | - Marius Junker
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt / Main, Germany
| | - Andrea Meurer
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt / Main, Germany
| | - Frank Zaucke
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt / Main, Germany
| | - Zsuzsa Jenei-Lanzl
- Dr. Rolf M. Schwiete Research Unit for Osteoarthritis, Department of Orthopedics (Friedrichsheim), University Hospital Frankfurt, Goethe University, Frankfurt / Main, Germany.
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Blumer R, Boesmueller S, Gesslbauer B, Hirtler L, Bormann D, Pastor AM, Streicher J, Mittermayr R. Structural and molecular characteristics of axons in the long head of the biceps tendon. Cell Tissue Res 2019; 380:43-57. [PMID: 31811408 DOI: 10.1007/s00441-019-03141-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/07/2019] [Indexed: 11/30/2022]
Abstract
The innervation of the long head of the biceps tendon (LHBT) is not sufficiently documented. This is a drawback since pathologies of the LHBT are a major source of shoulder pain. Thus, the study aimed to characterize structurally and molecularly nervous elements of the LHBT. The proximal part of 11 LHBTs was harvested intraoperatively. There were 8 female and 3 male specimens. Age ranged from 66 to 86 years. For structural analyses, nervous elements were viewed in the transmission electron microscope. For molecular characterization, we used general neuronal markers including antibodies against neurofilament and protein gene product 9.5 (PGP9.5) as well as specific neuronal markers including antibodies against myelin basic protein (MBP), calcitonin gene-related product (CGRP), substance P (SP), tyrosine hydroxylase (TH), and growth-associated protein 43 (GAP43). Anti-neurofilament and anti-PGP9.5 visualized the overall innervation. Anti-MBP visualized myelination, anti-CGRP and anti-SP nociceptive fibers, anti-TH sympathetic nerve fibers, and anti-GAP43 nerve fibers during development and regeneration. Immunolabeled sections were analyzed in the confocal laser scanning microscope. We show that the LHBT contains unmyelinated as well as myelinated nerve fibers which group in nerve fascicles and follow blood vessels. Manny myelinated and unmyelinated axons exhibit molecular features of nociceptive nerve fibers. Another subpopulation of unmyelinated axons exhibits molecular characteristics of sympathetic nerve fibers. Unmyelinated sympathetic fibers and unmyelinated nociceptive fibers express proteins that are found during development and regeneration. Present findings support the hypothesis that ingrowth of nociceptive fibers are the source of chronic tendon pain.
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Affiliation(s)
- Roland Blumer
- Center of Anatomy and Cell Biology, MIC, Medical University Vienna, A-1090, Vienna, Austria.
| | | | - Bernhard Gesslbauer
- Department of Surgery, Division of Plastic and Reconstruction Surgery, Medical University Vienna, A-1090, Vienna, Austria
| | - Lena Hirtler
- Center of Anatomy and Cell Biology, MIC, Medical University Vienna, A-1090, Vienna, Austria
| | - Daniel Bormann
- Center of Anatomy and Cell Biology, MIC, Medical University Vienna, A-1090, Vienna, Austria
| | - Angel M Pastor
- Departamento de Fisiología, Facultad de Biología, Universidad de Sevilla, 41012, Sevilla, Spain
| | - Johannes Streicher
- Department of Anatomy and Biomechanics, Division of Anatomy and Developmental Biology, Karl Landsteiner University of Health Science, A-3500, Krems an der Donau, Austria
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Beccati F, Pepe M, Antinori L, Pascucci L, Chiaradia E, Mandara MT. Sympathetic Innervation and Adrenergic Receptors in Equine Deep Digital Flexor Tendinopathy: Preliminary Results. J Comp Pathol 2018; 163:33-37. [PMID: 30213372 DOI: 10.1016/j.jcpa.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 12/01/2022]
Abstract
The aim of this study was to delineate the pattern of sympathetic innervation in the suprasesamoidean region of the deep digital flexor tendon (DDFT) in horses with tendinopathy by immunohistochemical labelling for tyrosine hydroxylase (TH) and α-1 adrenergic receptor (α1-AR). Twelve forelimbs were obtained from 10 horses with DDFT tendinopathy and six feet obtained from six horses were used as healthy controls. Post-mortem radiographic, ultrasonographic and gross examinations were performed on the suprasesamoidean area of the DDFT to assess the presence of tendinopathy. Longitudinal sections were collected and processed. Lesions were classified as core lesions, dorsal border lesions and parasagittal oblique splits. Immunohistochemistry was performed and the degree of immunoreaction was classified as absent, mild or marked. Seven core lesions, four dorsal border lesions and one parasagittal oblique split were identified. There was no increased expression of sympathetic innervation in samples with a dorsal border lesion of the DDFT compared with healthy samples. In contrast, core lesions showed increased expression of α1-AR and reduced expression of TH, which supports the hypothesis of a compensatory imbalance between the sympathetic mediator and the sympathetic receptors as a cause or effect of structural damage. In addition, adrenergic activation could stimulate cell proliferation and differentiation within these lesions.
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Affiliation(s)
- F Beccati
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy.
| | - M Pepe
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
| | - L Antinori
- Clinica Veterinaria Roma Sud, Via Pilade Mazza, 24, Roma, Italy
| | - L Pascucci
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
| | - E Chiaradia
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
| | - M T Mandara
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
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Lipman K, Wang C, Ting K, Soo C, Zheng Z. Tendinopathy: injury, repair, and current exploration. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:591-603. [PMID: 29593382 PMCID: PMC5865563 DOI: 10.2147/dddt.s154660] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Both acute and chronic tendinopathy result in high morbidity, requiring management that is often lengthy and expensive. However, limited and conflicting scientific evidence surrounding current management options has presented a challenge when trying to identify the best treatment for tendinopathy. As a result of shortcomings of current treatments, response to available therapies is often poor, resulting in frustration in both patients and physicians. Due to a lack of understanding of basic tendon-cell biology, further scientific investigation is needed in the field for the development of biological solutions. Optimization of new delivery systems and therapies that spatially and temporally mimic normal tendon physiology hold promise for clinical application. This review focuses on the clinical importance of tendinopathy, the structure of healthy tendons, tendon injury, and healing, and a discussion of current approaches for treatment that highlight the need for the development of new nonsurgical interventions.
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Affiliation(s)
| | - Chenchao Wang
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA.,First Hospital of China Medical University, Shenyang, China.,Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, University of California, Los Angeles, CA, USA
| | - Kang Ting
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA
| | - Chia Soo
- Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, University of California, Los Angeles, CA, USA
| | - Zhong Zheng
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA
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11
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Jewson JL, Lambert EA, Docking S, Storr M, Lambert GW, Gaida JE. Pain duration is associated with increased muscle sympathetic nerve activity in patients with Achilles tendinopathy. Scand J Med Sci Sports 2016; 27:1942-1949. [DOI: 10.1111/sms.12820] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2016] [Indexed: 12/19/2022]
Affiliation(s)
- J. L. Jewson
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Vic. Australia
| | - E. A. Lambert
- Human Neurotransmitters Laboratory; Baker IDI Heart and Diabetes Institute; Melbourne Vic. Australia
- Department of Physiology; Monash University; Melbourne Vic. Australia
| | - S. Docking
- Department of Physiotherapy; Monash University; Melbourne Vic. Australia
- Australian Centre for Research into Injury in Sport and its Prevention; Federation University; Ballarat Vic. Australia
| | - M. Storr
- Department of Physiotherapy; Monash University; Melbourne Vic. Australia
| | - G. W. Lambert
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Vic. Australia
- Human Neurotransmitters Laboratory; Baker IDI Heart and Diabetes Institute; Melbourne Vic. Australia
| | - J. E. Gaida
- Department of Physiotherapy; Monash University; Melbourne Vic. Australia
- University of Canberra Research Institute for Sport and Exercise (UC-RISE); Canberra ACT Australia
- Discipline of Physiotherapy; University of Canberra; Canberra ACT Australia
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Vasta S, Di Martino A, Zampogna B, Torre G, Papalia R, Denaro V. Role of VEGF, Nitric Oxide, and Sympathetic Neurotransmitters in the Pathogenesis of Tendinopathy: A Review of the Current Evidences. Front Aging Neurosci 2016; 8:186. [PMID: 27555817 PMCID: PMC4977280 DOI: 10.3389/fnagi.2016.00186] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 07/19/2016] [Indexed: 12/30/2022] Open
Abstract
Chronic tendinopathy is a painful common condition affecting athletes as well as the general population undergoing to tendon overuse. Although its huge prevalence, little is known about tendinopathy pathogenesis, and even cloudier is its treatment. Traditionally, tendinopathy has been defined as a lack of tendon ability to overcome stressing stimuli with appropriate adaptive changes. Histologic studies have demonstrated the absence of inflammatory infiltrates, as a consequence conventional antinflammatory drugs have shown little or no effectiveness in treating tendinopathies. New strategies should be therefore identified to address chronic tendon disorders. Angiofibroblastic changes have been highlighted as the main feature of tendinopathy, and vascular endothelial growth factor (VEGF) has been demonstrated as one of the key molecules involved in vascular hyperplasia. More recently, attention has been focused on new peptides such as Substance P, nitric oxide, and calcitonin gene-related peptide (CGRP). Those new findings support the idea of a nerve-mediated disregulation of tendon metabolism. Each of those molecules could be a target for new treatment options. This study aimed to systematically review the current available clinical and basic science in order to summarize the latest evidences on the pathophysiology and its effect on treatment of chronic tendinopathy, and to spread suggestions for future research on its treatment.
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Affiliation(s)
- Sebastiano Vasta
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome Rome, Italy
| | - Alberto Di Martino
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome Rome, Italy
| | - Biagio Zampogna
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome Rome, Italy
| | - Guglielmo Torre
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome Rome, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome Rome, Italy
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Jewson JL, Lambert GW, Storr M, Gaida JE. The sympathetic nervous system and tendinopathy: a systematic review. Sports Med 2016; 45:727-43. [PMID: 25655371 DOI: 10.1007/s40279-014-0300-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tendinopathy is a clinical diagnosis of localised tendon pain often confirmed by imaging findings. The pathophysiological cause of the pain is unknown and the sympathetic nervous system (SNS) may be implicated. OBJECTIVE To review what is known regarding the role of the SNS in human tendinopathy. STUDY SELECTION Published data describing sympathetic innervation or an index of sympathetic activity in human tendons were eligible for inclusion. DATA SOURCES Bibliographical databases (AMED, Biological Abstracts, CINAHL Plus, EMBASE, MEDLINE, Scopus, SPORTDiscus and Web of Science) were searched for relevant articles. Reference lists from included articles were screened for additional articles. STUDY APPRAISAL Studies were scored with a quality assessment tool to identify potential sources of bias. Each question had an explicit decision rule to guide assessment. RESULTS Nine case-control and four cross-sectional studies examined sympathetic innervation of tendons. There was evidence suggesting a lack of difference in sympathetic innervation of tendon proper between tendinopathy biopsies and healthy controls. In contrast, the paratendinous tissue showed evidence of increased sympathetic innervation in painful tendons. The most notable increase in SNS markers was seen in abnormal tenocytes from painful tendons. Data from two studies were suitable for meta-analysis. These heterogeneous studies revealed no difference in sympathetic innervation between painful and pain-free tendons. No studies recorded SNS activity in vivo. CONCLUSION Sympathetic innervation in painful tendons depends on tissue type. Abnormal tenocytes may have increased capacity for self-production of sympathetic neurotransmitters. Future insight may be gained by measuring global in vivo sympathetic drive in tendinopathy.
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Affiliation(s)
- Jacob L Jewson
- Central Medical School, Monash University, Melbourne, VIC, Australia,
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Beccati F, Pepe M, Pascucci L, Ceccarelli P, Chiaradia E, Mancini F, Mandara MT. Sympathetic innervation of the suprasesamoidean region of the deep digital flexor tendon in the forelimbs of horses. Vet J 2015; 205:413-6. [PMID: 26095033 DOI: 10.1016/j.tvjl.2015.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/03/2015] [Accepted: 06/04/2015] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to delineate the pattern of sympathetic innervation in the suprasesamoidean region of the deep digital flexor tendon (DDFT) in horses using immunohistochemical staining (IHC) for tyrosine hydroxylase (TH) and alpha-1 adrenergic receptor (α1-AR). Fourteen forelimbs were collected from 10 horses. Longitudinal sections of the suprasesamoidean region of healthy DDFTs were harvested. Most of the sympathetic innervation was found to be in the walls of blood vessels. The tendon tissue proper was sparsely innervated, with a lesser degree of innervation within the dorsal fibrocartilage. Increased α1-AR immunostaining was also detected in walls of blood vessels and in spindle cells of fibrocartilage. Both α1-AR and TH immunostaining were detected in tenocytes. These findings support the presence of autocrine/paracrine catecholaminergic signalling in equine tendon tissue.
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Affiliation(s)
- F Beccati
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy.
| | - M Pepe
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - L Pascucci
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - P Ceccarelli
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - E Chiaradia
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - F Mancini
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - M T Mandara
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
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Schiavuzzo JG, Teixeira JM, Melo B, da Silva dos Santos DF, Jorge CO, Oliveira-Fusaro MCG, Parada CA. Muscle hyperalgesia induced by peripheral P2X3 receptors is modulated by inflammatory mediators. Neuroscience 2014; 285:24-33. [PMID: 25446353 DOI: 10.1016/j.neuroscience.2014.11.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/06/2014] [Accepted: 11/11/2014] [Indexed: 11/25/2022]
Abstract
ATP, via activation of P2X3 receptors, has been highlighted as a key target in inflammatory hyperalgesia. Therefore, the aim of this study was to confirm whether the activation of P2X3 receptors in the gastrocnemius muscle of rats induces mechanical muscle hyperalgesia and, if so, to analyze the involvement of the classical inflammatory mediators (bradykinin, prostaglandins, sympathetic amines, pro-inflammatory cytokines and neutrophil migration) in this response. Intramuscular administration of the non-selective P2X3 receptor agonist α,β-meATP in the gastrocnemius muscle of rats induced mechanical muscle hyperalgesia, which, in turn, was prevented by the selective P2X3 and P2X2/3 receptors antagonist A-317491, the selective bradykinin B1-receptor antagonist Des-Arg9-[Leu8]-BK (DALBK), the cyclooxygenase inhibitor indomethacin, the β1- or β2-adrenoceptor antagonist atenolol and ICI 118,551, respectively. Also, the nonspecific selectin inhibitor fucoidan. α,β-meATP induced increases in the local concentration of the pro-inflammatory cytokines tumor necrosis factor-α (TNF-α) and interleukin 1β (IL-1β), which were reduced by bradykinin antagonist. Finally, α,β-meATP also induced neutrophil migration. Together, these findings suggest that α,β-meATP induced mechanical hyperalgesia in the gastrocnemius muscle of rats via activation of peripheral P2X3 receptors, which involves bradykinin, prostaglandins, sympathetic amines, pro-inflammatory cytokines release and neutrophil migration. It is also indicated that bradykinin is the key modulator of the mechanical muscle hyperalgesia induced by P2X3 receptors. Therefore, we suggest that P2X3 receptors are important targets to control muscle inflammatory pain.
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Affiliation(s)
- J G Schiavuzzo
- Laboratory of Studies of Pain and Inflammation, School of Applied Sciences - UNICAMP, Limeira, Sao Paulo, Brazil; Department of Structural and Functional Biology, Institute of Biology, State University of Campinas - UNICAMP, Campinas, Sao Paulo, Brazil
| | - J M Teixeira
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas - UNICAMP, Campinas, Sao Paulo, Brazil
| | - B Melo
- Laboratory of Studies of Pain and Inflammation, School of Applied Sciences - UNICAMP, Limeira, Sao Paulo, Brazil
| | - D F da Silva dos Santos
- Laboratory of Studies of Pain and Inflammation, School of Applied Sciences - UNICAMP, Limeira, Sao Paulo, Brazil
| | - C O Jorge
- Laboratory of Studies of Pain and Inflammation, School of Applied Sciences - UNICAMP, Limeira, Sao Paulo, Brazil
| | - M C G Oliveira-Fusaro
- Laboratory of Studies of Pain and Inflammation, School of Applied Sciences - UNICAMP, Limeira, Sao Paulo, Brazil.
| | - C A Parada
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas - UNICAMP, Campinas, Sao Paulo, Brazil
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Biernat R, Trzaskoma Z, Trzaskoma L, Czaprowski D. Rehabilitation protocol for patellar tendinopathy applied among 16- to 19-year old volleyball players. J Strength Cond Res 2014; 28:43-52. [PMID: 23669814 DOI: 10.1519/jsc.0b013e31829797b4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The aim of the study was to investigate the efficacy of rehabilitation protocol applied during competitive period for the treatment of patellar tendinopathy. A total of 28 male volleyball players were divided into two groups. Fifteen from experimental group (E) and 13 from control group (C) fulfilled the same tests 3 times: before the training program started (first measurement), after 12 weeks (second measurement) and after 24 weeks (third measurement). The above-mentioned protocol included the following: USG imagining with color Doppler function, clinical testing, pain intensity evaluation with VISA-P questionnaire, leg muscle strength and power and jumping ability measurements. The key element of the rehabilitation program was eccentric squat on decline board with additional unstable surface. The essential factor of the protocol was a set of preventive functional exercises, with focus on eccentric exercises of hamstrings. Patellar tendinopathy was observed in 18% of the tested young volleyball players. Implementation of the presented rehabilitation protocol with eccentric squat on decline board applied during sports season lowered the pain level of the young volleyball players. Presented rehabilitation protocol applied without interrupting the competitive period among young volleyball players together with functional exercises could be an effective method for the treatment of patellar tendinopathy.
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Affiliation(s)
- Ryszard Biernat
- 1Józef Rusiecki Higher School in Olsztyn, Olsztyn, Poland; 2The Jozef Pilsudski University of Physical Education in Warsaw, Warsaw, Poland; and 3Department of Biomechanics, Kinesiology and Informatics, Faculty of Physical Education and Sport Sciences, Semmelweis University, Budapest, Hungary
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Rio E, Moseley L, Purdam C, Samiric T, Kidgell D, Pearce AJ, Jaberzadeh S, Cook J. The Pain of Tendinopathy: Physiological or Pathophysiological? Sports Med 2013; 44:9-23. [DOI: 10.1007/s40279-013-0096-z] [Citation(s) in RCA: 172] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Backman LJ, Eriksson DE, Danielson P. Substance P reduces TNF-α-induced apoptosis in human tenocytes through NK-1 receptor stimulation. Br J Sports Med 2013; 48:1414-20. [PMID: 23996004 PMCID: PMC4173875 DOI: 10.1136/bjsports-2013-092438] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background It has been hypothesised that an upregulation of the neuropeptide substance P (SP) and its preferred receptor, the neurokinin-1 receptor (NK-1 R), is a causative factor in inducing tenocyte hypercellularity, a characteristic of tendinosis, through both proliferative and antiapoptotic stimuli. We have demonstrated earlier that SP stimulates proliferation of human tenocytes in culture. Aim The aim of this study was to investigate whether SP can mediate an antiapoptotic effect in tumour necrosis factor-α (TNF-α)-induced apoptosis of human tenocytes in vitro. Results A majority (approximately 75%) of tenocytes in culture were immunopositive for TNF Receptor-1 and TNF Receptor-2. Exposure of the cells to TNF-α significantly decreased cell viability, as shown with crystal violet staining. TNF-α furthermore significantly increased the amount of caspase-10 and caspase-3 mRNA, as well as both BID and cleaved-poly ADP ribosome polymerase (c-PARP) protein. Incubation of SP together with TNF-α resulted in a decreased amount of BID and c-PARP, and in a reduced lactate dehydrogenase release, as compared to incubation with TNF-α alone. The SP effect was blocked with a NK-1 R inhibitor. Discussion This study shows that SP, through stimulation of the NK-1 R, has the ability to reduce TNF-α-induced apoptosis of human tenocytes. Considering that SP has previously been shown to stimulate tenocyte proliferation, the study confirms SP as a potent regulator of cell-turnover in tendon tissue, capable of stimulating hypercellularity through different mechanisms. This gives further support for the theory that the upregulated amount of SP seen in tendinosis could contribute to hypercellularity.
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Affiliation(s)
- Ludvig J Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden Department of Surgical and Perioperative Sciences, Sports Medicine, Umeå University, Umeå, Sweden
| | - Daniella E Eriksson
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
| | - Patrik Danielson
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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Ackermann PW. Neuronal regulation of tendon homoeostasis. Int J Exp Pathol 2013; 94:271-86. [PMID: 23718724 PMCID: PMC3721458 DOI: 10.1111/iep.12028] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 04/16/2013] [Indexed: 12/25/2022] Open
Abstract
The regulation of tendon homoeostasis, including adaptation to loading, is still not fully understood. Accumulating data, however, demonstrates that in addition to afferent (sensory) functions, the nervous system, via efferent pathways which are associated with through specific neuronal mediators plays an active role in regulating pain, inflammation and tendon homeostasis. This neuronal regulation of intact-, healing- and tendinopathic tendons has been shown to be mediated by three major groups of molecules including opioid, autonomic and excitatory glutamatergic neuroregulators. In intact healthy tendons the neuromediators are found in the surrounding structures: paratenon, endotenon and epitenon, whereas the proper tendon itself is practically devoid of neurovascular supply. This neuroanatomy reflects that normal tendon homoeostasis is regulated from the tendon surroundings. After injury and during tendon repair, however, there is extensive nerve ingrowth into the tendon proper, followed by a time-dependent emergence of sensory, autonomic and glutamatergic mediators, which amplify and fine-tune inflammation and regulate tendon regeneration. In tendinopathic condition, excessive and protracted presence of sensory and glutamatergic neuromediators has been identified, suggesting involvement in inflammatory, nociceptive and hypertrophic (degenerative) tissue responses. Under experimental and clinical conditions of impaired (e.g. diabetes) as well as excessive (e.g. tendinopathy) neuromediator release, dysfunctional tendon homoeostasis develops resulting in chronic pain and gradual degeneration. Thus there is a prospect that in the future pharmacotherapy and tissue engineering approaches targeting neuronal mediators and their receptors may prove to be effective therapies for painful, degenerative and traumatic tendon disorders.
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Affiliation(s)
- Paul W Ackermann
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden.
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Gammaitoni AR, Goitz HT, Marsh S, Marriott TB, Galer BS. Heated lidocaine/tetracaine patch for treatment of patellar tendinopathy pain. J Pain Res 2013; 6:565-70. [PMID: 23888118 PMCID: PMC3722138 DOI: 10.2147/jpr.s46239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The pain of patellar tendinopathy (PT) may be mediated by neuronal glutamate and sodium channels. Lidocaine and tetracaine block both of these channels. This study tested the self-heated lidocaine-tetracaine patch (HLT patch) in patients with PT confirmed by physical examination to determine if the HLT patch might relieve pain and improve function. METHODS Thirteen patients with PT pain of ≥14 days' duration and baseline average pain scores ≥4 (on a 0-10 scale) enrolled in and completed this prospective, single-center pilot study. Patients applied one HLT patch to the affected knee twice daily for 2-4 hours for a total of 14 days. Change in average pain intensity and interference (Victorian Institute of Sport Assessment [VISA]) scores from baseline to day 14 were assessed. No statistical inference testing was performed. RESULTS Average pain scores declined from 5.5 ± 1.3 (mean ± standard deviation) at baseline to 3.8 ± 2.5 on day 14. Similarly, VISA scores improved from 45.2 ± 14.4 at baseline to 54.3 ± 24.5 on day 14. A clinically important reduction in pain score (≥30%) was demonstrated by 54% of patients. CONCLUSION The results of this pilot study suggest that topical treatment that targets neuronal sodium and glutamate channels may be useful in the treatment of PT.
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Danielson P. ROLE OF NEUROPEPTIDES AND OTHER NEUROMODULATORS IN TENDINOPATHY PATHOGENESIS. Br J Sports Med 2013. [DOI: 10.1136/bjsports-2013-092459.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Scott A, Docking S, Vicenzino B, Alfredson H, Murphy RJ, Carr AJ, Zwerver J, Lundgreen K, Finlay O, Pollock N, Cook JL, Fearon A, Purdam CR, Hoens A, Rees JD, Goetz TJ, Danielson P. Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J Sports Med 2013; 47:536-44. [PMID: 23584762 PMCID: PMC3664390 DOI: 10.1136/bjsports-2013-092329] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In September 2010, the first International Scientific Tendinopathy Symposium (ISTS) was held in Umeå, Sweden, to establish a forum for original scientific and clinical insights in this growing field of clinical research and practice. The second ISTS was organised by the same group and held in Vancouver, Canada, in September 2012. This symposium was preceded by a round-table meeting in which the participants engaged in focused discussions, resulting in the following overview of tendinopathy clinical and research issues. This paper is a narrative review and summary developed during and after the second ISTS. The document is designed to highlight some key issues raised at ISTS 2012, and to integrate them into a shared conceptual framework. It should be considered an update and a signposting document rather than a comprehensive review. The document is developed for use by physiotherapists, physicians, athletic trainers, massage therapists and other health professionals as well as team coaches and strength/conditioning managers involved in care of sportspeople or workers with tendinopathy.
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Affiliation(s)
- Alex Scott
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada.
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Tosounidis T, Hadjileontis C, Triantafyllou C, Sidiropoulou V, Kafanas A, Kontakis G. Evidence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon. J Orthop Sci 2013; 18:238-44. [PMID: 23306538 DOI: 10.1007/s00776-012-0346-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 12/05/2012] [Indexed: 02/09/2023]
Abstract
BACKGROUND The primary purpose of this study was to investigate the sympathetic innervation of the long head of the biceps brachii tendon LHB via immunohistochemical staining for protein S-100 and neuropeptide Y (NPY) in patients with complex proximal humerus fractures, in individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC), and in cadaveric samples with no previously reported shoulder pathology. METHODS We investigated the presence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon (LHB) in patients with complex proximal humerus fractures and individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC). The correlation of morphological features with immunohistochemical evidence of neural element presence was also investigated. Forty-one LHB tendon specimens were examined. Seventeen were harvested from patients who underwent hemiarthroplasty for proximal humerus fractures, 14 were from individuals with biceps tendinosis in the context of a large RC tear, and ten were from cadaveric controls with no previous shoulder pathology. Histologic examination was performed using hematoxylin and eosin. Immunohistochemistry was used to detect the expression of the protein S-100, neuropeptide Y, and α1-adrenergic receptors, as well as to characterize the potential neural differentiation of tendon cells. RESULTS A strong correlation between the expression of NPY/S-100, α1-adrenergic/S-100, and α1-adrenergic/NPY was found. The LHB tendon has sympathetic innervation and α1-adrenergic receptors in acute and chronic pathological conditions. CONCLUSION Our results provide useful guidance on the management of tendinosis and the handling of the LHB in hemiarthroplasties for fractures.
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Affiliation(s)
- Theodoros Tosounidis
- University Hospital of Heraklion, 1 Pindarou Str, 71305 Heraklion, Crete, Greece.
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Alfredson H, Spang C, Forsgren S. Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery. Br J Sports Med 2012. [PMID: 23193327 DOI: 10.1136/bjsports-2012-091399] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Bilateral midportion Achilles tendinopathy/tendinosis is not unusual, and treatment of both sides is often carried out. Experiments in animals suggest of the potential involvement of central neuronal mechanisms in Achilles tendinosis. OBJECTIVES To evaluate the outcome of surgery for Achilles tendinopathy. METHODS This observational study included 13 patients (7 men and 6 women, mean age 53 years) with a long duration (6-120 months) of chronic painful bilateral midportion Achilles tendinopathy. The most painful side at the time for investigation was selected to be operated on first. Treatment was ultrasound-guided and Doppler-guided scraping procedure outside the ventral part of the tendon under local anaesthetic. The patients started walking on the first day after surgery. Follow-ups were conducted and the primary outcome was pain by visual analogue scale. In an additional part of the study, specimens from Achilles and plantaris tendons in three patients with bilateral Achilles tendinosis were examined. RESULTS Short-term follow-ups showed postoperative improvement on the non-operated side as well as the operated side in 11 of 13 patients. Final follow-up after 37 (mean) months showed significant pain relief and patient satisfaction on both sides for these 11 patients. In 2 of 13 patients operation on the other, initially non-operated side, was instituted due to persisting pain. Morphologically, it was found that there were similar morphological effects, and immunohistochemical patterns of enzyme involved in signal substance production, bilaterally. CONCLUSION Unilateral treatment with a scraping operation can have benefits contralaterally; the clinical implication is that unilateral surgery may be a logical first treatment in cases of bilateral Achilles tendinopathy.
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Affiliation(s)
- Håkan Alfredson
- Department of Surgical and Perioperative Sciences, Sports Medicine, Umeå University, Umeå, Sweden
| | - Christoph Spang
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Umeå, Sweden
| | - Sture Forsgren
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Umeå, Sweden
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Abstract
Tendinosis is a troublesome clinical entity affecting many active people. Its treatment remains a challenge to sports medicine clinicians. The etiopathophysiology of tendinosis has not been well delineated. The known pathophysiology and the recent advances in the understanding of the etiologic process of tendinosis are discussed here, including new concepts in mechanotransduction and the biochemical alterations that occur during tendon overload. The optimal, nonoperative treatment of tendinosis is not clear. This article reviews recent evidence of the clinical efficacy of the following interventions: eccentric exercise, extracorporal shock wave treatment, corticosteroid and nonsteroidal anti-inflammatory medications, sclerosing injections, nitric oxide, platelet-rich plasma injections, and matrix metalloproteinase inhibitors. Eccentric exercise has strongest evidence of efficacy. Extracorporal shock wave treatment has mixed evidence and needs further study of energy and application protocols. Sclerosing agents show promising early results but require long-term studies. Corticosteroid and nonsteroidal anti-inflammatory medications have not been shown to be effective, and many basic science studies raise possible concerns with their use. Nitric oxide has been shown in several basic science studies to be promising, but clinical efficacy has not been well established. More clinical trials are needed to assess dosing, indications, and clinical efficacy of nitric oxide. Platelet-rich plasma injections have offered encouraging short-term results. Larger and longer-term clinical trials are needed to assess this promising modality. Matrix metalloproteinase inhibitors have had few clinical studies, and their role in the treatment of tendinosis is still in the early phase of investigation.
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Affiliation(s)
- Christopher Kaeding
- Address correspondence to Christopher Kaeding, MD, The Ohio State University, Sports Medicine Center, 2050 Kenny Road, Suite 3100, Columbus, OH 43221 (e-mail: )
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Katori Y, Shibata S, Kawase T, Cho BH, Murakami G. Transient Appearance of Tyrosine Hydroxylase Immunoreactive Cells in the Midline Epithelial Seam of the Human Fetal Secondary Palate. Cleft Palate Craniofac J 2012; 49:414-24. [DOI: 10.1597/10-121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Transient immunoreactivity for tyrosine hydroxylase, which mediates the conversion of the amino acid L-tyrosine to dihydroxyphenylalanine, in the midline epithelial seam between the bilateral palatal shelves was investigated in human fetuses. Materials and Methods Horizontal or frontal paraffin sections of two human fetuses at 9 and 15 weeks of gestation were used to examine the distribution of tyrosine hydroxylase–immunoreactive cells in regions of the entire head other than the brain. Immunohistochemical staining for S100 protein, calretinin, cytokeratin 14, and vimentin was examined using adjacent or near sections. Results Tyrosine hydroxylase–immunoreactive cells were large and densely distributed in the midline epithelial seam at the site of palatal fusion in fetuses at 9 weeks but not in fetuses at 15 weeks, in which the midline epithelial seam had already disappeared. No expression of S100 protein, calretinin, or vimentin was detected, but the midline epithelial seam was positive for cytokeratin 14. Tyrosine hydroxylase immunoreactivity was not detected in epithelia during the process of palatal fusion in mice from E 14.0 to 15.0. Conclusions These findings indicate that tyrosine hydroxylase–immunoreactive cells in the midline epithelial seams are nonneural epithelial cells and suggest that the tyrosine hydroxylase is a novel factor involved in normal palatal formation, especially the fate of the midline epithelial seam in humans.
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Affiliation(s)
| | - Shunichi Shibata
- Division of Histology, Department of Oral Growth and Development, School of Dentistry, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Tetsuaki Kawase
- Department of Otorhinolaryngology, Laboratory of Rehabilitative Auditory Science, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Baik Hwan Cho
- Department of Surgery, Faculty of Medicine, Chonbuk National University, Jeonju, Jeonbuk, South Korea
| | - Gen Murakami
- Division of Internal Medicine, Iwamizawa Koujin-kai Hospital, Iwamizawa, Hokkaido, Japan
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Fernando Radice D. Lesiones tendinosas en medicina del deporte: Ciencias básicas aplicadas al tratamiento actual. REVISTA MÉDICA CLÍNICA LAS CONDES 2012. [DOI: 10.1016/s0716-8640(12)70312-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Backman LJ, Andersson G, Fong G, Alfredson H, Scott A, Danielson P. Alpha-2 adrenergic stimulation triggers Achilles tenocyte hypercellularity: Comparison between two model systems. Scand J Med Sci Sports 2012; 23:687-96. [PMID: 22292987 PMCID: PMC3933766 DOI: 10.1111/j.1600-0838.2011.01442.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2011] [Indexed: 11/29/2022]
Abstract
The histopathology of tendons with painful tendinopathy is often tendinosis, a fibrosis-like condition of unclear pathogenesis characterized by tissue changes including hypercellularity. The primary tendon cells (tenocytes) have been shown to express adrenoreceptors (mainly alpha-2A) as well as markers of catecholamine production, particularly in tendinosis. It is known that adrenergic stimulation can induce proliferation in other cells. The present study investigated the effects of an exogenously administered alpha-2 adrenergic agonist in an established in vivo Achilles tendinosis model (rabbit) and also in an in vitro human tendon cell culture model. The catecholamine producing enzyme tyrosine hydroxylase and the alpha-2A-adrenoreceptor (α2A AR) were expressed by tenocytes, and alpha-2 adrenergic stimulation had a proliferative effect on these cells, in both models. The proliferation was inhibited by administration of an α2A AR antagonist, and the in vitro model further showed that the proliferative alpha-2A effect was mediated via a mitogenic cell signaling pathway involving phosphorylation of extracellular-signal-regulated kinases 1 and 2. The results indicate that catecholamines produced by tenocytes in tendinosis might contribute to the proliferative nature of the pathology through stimulation of the α2A AR, pointing to a novel target for future therapies. The study furthermore shows that animal models are not necessarily required for all aspects of this research.
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Affiliation(s)
- L J Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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Forsgren S, Alfredson H, Bjur D, Rantapää-Dahlqvist S, Norrgård O, Dalén T, Danielson P. Novel information on the non-neuronal cholinergic system in orthopedics provides new possible treatment strategies for inflammatory and degenerative diseases. Orthop Rev (Pavia) 2011; 1:e11. [PMID: 21808665 PMCID: PMC3143960 DOI: 10.4081/or.2009.e11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 06/23/2009] [Accepted: 06/26/2009] [Indexed: 01/14/2023] Open
Abstract
Anti-cholinergic agents are used in the treatment of several pathological conditions. Therapy regimens aimed at up-regulating cholinergic functions, such as treatment with acetylcholinesterase inhibitors, are also currently prescribed. It is now known that not only is there a neuronal cholinergic system but also a non-neuronal cholinergic system in various parts of the body. Therefore, interference with the effects of acetylcholine (ACh) brought about by the local production and release of ACh should also be considered. Locally produced ACh may have proliferative, angiogenic, wound-healing, and immunomodulatory functions. Interestingly, cholinergic stimulation may lead to anti-inflammatory effects. Within this review, new findings for the locomotor system of a more widespread non-neuronal cholinergic system than previously expected will be discussed in relation to possible new treatment strategies. The conditions discussed are painful and degenerative tendon disease (tendinopathy/tendinosis), rheumatoid arthritis, and osteoarthritis.
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Affiliation(s)
- Sture Forsgren
- Dept. of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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31
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Backman LJ, Fong G, Andersson G, Scott A, Danielson P. Substance P is a mechanoresponsive, autocrine regulator of human tenocyte proliferation. PLoS One 2011; 6:e27209. [PMID: 22069500 PMCID: PMC3206074 DOI: 10.1371/journal.pone.0027209] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/11/2011] [Indexed: 11/19/2022] Open
Abstract
It has been hypothesised that substance P (SP) may be produced by primary fibroblastic tendon cells (tenocytes), and that this production, together with the widespread distribution of the neurokinin-1 receptor (NK-1 R) in tendon tissue, could play an important role in the development of tendinopathy, a condition of chronic tendon pain and thickening. The aim of this study was to examine the possibility of endogenous SP production and the expression of NK-1 R by human tenocytes. Because tendinopathy is related to overload, and because the predominant tissue pathology (tendinosis) underlying early tendinopathy is characterized by tenocyte hypercellularity, the production of SP in response to loading/strain and the effects of exogenously administered SP on tenocyte proliferation were also studied. A cell culture model of primary human tendon cells was used. The vast majority of tendon cells were immunopositive for the tenocyte/fibroblast markers tenomodulin and vimentin, and immunocytochemical counterstaining revealed that positive immunoreactions for SP and NK-1 R were seen in a majority of these cells. Gene expression analyses showed that mechanical loading (strain) of tendon cell cultures using the FlexCell© technique significantly increased the mRNA levels of SP, whereas the expression of NK-1 R mRNA decreased in loaded as compared to unloaded tendon cells. Reduced NK-1 R protein was also observed, using Western blot, after exogenously administered SP at a concentration of 10−7 M. SP exposure furthermore resulted in increased cell metabolism, increased cell viability, and increased cell proliferation, all of which were found to be specifically mediated via the NK-1 R; this in turn involving a common mitogenic cell signalling pathway, namely phosphorylation of ERK1/2. This study indicates that SP, produced by tenocytes in response to mechanical loading, may regulate proliferation through an autocrine loop involving the NK-1 R.
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Affiliation(s)
- Ludvig J. Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Sports Medicine, Umeå University, Umeå, Sweden
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gloria Fong
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health and Research Institute, Vancouver, British Columbia, Canada
| | - Gustav Andersson
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
| | - Alexander Scott
- Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Hip Health and Mobility, Vancouver Coastal Health and Research Institute, Vancouver, British Columbia, Canada
| | - Patrik Danielson
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
- * E-mail:
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Dawson LF, Phillips JK, Finch PM, Inglis JJ, Drummond PD. Expression of α1-adrenoceptors on peripheral nociceptive neurons. Neuroscience 2010; 175:300-14. [PMID: 21182905 DOI: 10.1016/j.neuroscience.2010.11.064] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 11/26/2010] [Accepted: 11/30/2010] [Indexed: 01/06/2023]
Abstract
The purpose of this study was to determine whether α(1)-adrenoceptors are expressed on primary nociceptive afferents that innervate healthy skin. Skin and dorsal root ganglia were collected from adult male Wistar rats and assessed using fluorescence immunohistochemistry with antibodies directed against α(1)-adrenoceptors alone or in combination with specific labels including myelin basic protein and neurofilament 200 (markers of myelinated nerve fibres), protein gene product 9.5 (a pan-neuronal marker), tyrosine hydroxylase (sympathetic neurons), isolectin B(4) (IB(4): non-peptidergic sensory neurons), calcitonin gene related peptide (CGRP) and transient receptor potential vanilloid receptor 1 (TRPV1) (peptidergic sensory neurons). Double labelling in dorsal root ganglia confirmed the expression of α(1)-adrenoceptors within sub-populations of CGRP, IB(4) and TRPV1 immunoreactive neurons. Myelinated and unmyelinated sensory nerve fibres in the skin expressed α(1)-adrenoceptors whereas sympathetic nerve fibres did not. The expression of α(1)-adrenoceptors on C- and A-delta nociceptive afferent fibres provides a histochemical substrate for direct excitation of these fibres by adrenergic agonists. This may help to explain the mechanism of sensory-sympathetic coupling that sometimes develops on surviving primary nociceptive afferents in neuropathic pain states.
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Affiliation(s)
- L F Dawson
- Faculty of Health Sciences, Murdoch University, Perth, Western Australia
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Tosounidis T, Hadjileontis C, Georgiadis M, Kafanas A, Kontakis G. The tendon of the long head of the biceps in complex proximal humerus fractures: a histological perspective. Injury 2010; 41:273-8. [PMID: 20176166 DOI: 10.1016/j.injury.2009.09.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Revised: 07/22/2009] [Accepted: 09/04/2009] [Indexed: 02/02/2023]
Abstract
We have studied the histologic and immunohistochemical changes of the long head of the biceps brachii tendon (LHB) in low-energy complex proximal humerus fractures. Our objective was to detect histological features, which may be correlated to pain generation. Biopsy samples were obtained during hemiarthroplasty procedures from 11 patients who suffered a complex proximal humerus fracture. The control group consisted of 10 samples harvested from human cadavers with no history of premortem shoulder problems and no gross shoulder pathology. Histologic investigation included quantitative measurement of tendon degeneration, cellularity, neoangiogenesis, inflammation and metaplasia, as well as immunohistochemical detection of cells with neural differentiation within the tendon tissue proper with S-100 protein and neuropeptide Y (N-Y). The found lesions were significantly more in the group of tendons from fractures compared to the control group (p<0.001). These lesions were also statistically correlated to each other, indicating a possible neural differentiation of tendon stromal cells. The LHB is a potential source of pain and the routine use of tenotomy/tenodesis of this tendon in hemiarthroplasty procedures for fracture may be reinforced by the results of this study.
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Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009; 19:790-802. [PMID: 19793213 DOI: 10.1111/j.1600-0838.2009.00949.x] [Citation(s) in RCA: 267] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A randomized-controlled single-blind trial was conducted to investigate the clinical, structural and functional effects of peritendinous corticosteroid injections (CORT), eccentric decline squat training (ECC) and heavy slow resistance training (HSR) in patellar tendinopathy. Thirty-nine male patients were randomized to CORT, ECC or HSR for 12 weeks. We assessed function and symptoms (VISA-p questionnaire), tendon pain during activity (VAS), treatment satisfaction, tendon swelling, tendon vascularization, tendon mechanical properties and collagen crosslink properties. Assessments were made at 0 weeks, 12 weeks and at follow-up (half-year). All groups improved in VISA-p and VAS from 0 to 12 weeks (P<0.05). VISA-p and VAS improvements were maintained at follow-up in ECC and HSR but deteriorated in CORT (P<0.05). In CORT and HSR, tendon swelling decreased (-13+/-9% and -12+/-13%, P<0.05) and so did vascularization (-52+/-49% and -45+/-23%, P<0.01) at 12 weeks. Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. HSR yielded an elevated collagen network turnover. At the half-year follow-up, treatment satisfaction differed between groups, with HSR being most satisfied. Conclusively, CORT has good short-term but poor long-term clinical effects, in patellar tendinopathy. HSR has good short- and long-term clinical effects accompanied by pathology improvement and increased collagen turnover.
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Affiliation(s)
- M Kongsgaard
- Institute of Sports Medicine, Department 8, Bispebjerg Hospital and Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Forsgren S, Grimsholm O, Jönsson M, Alfredson H, Danielson P. New insight into the non-neuronal cholinergic system via studies on chronically painful tendons and inflammatory situations. Life Sci 2009; 84:865-70. [PMID: 19409915 DOI: 10.1016/j.lfs.2009.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 04/14/2009] [Accepted: 04/17/2009] [Indexed: 11/29/2022]
Abstract
For certain parts of the body, it is nowadays accepted that there is a cholinergic system that is not related to cholinergic innervation, i.e. a non-neuronal cholinergic system. It might be argued that this system is of minor importance. New information obtained shows, however, that the non-neuronal cholinergic system is more widely distributed in the body than what is previously recognised. In recent studies, the existence of such a system has thus been shown for human tendons, especially in chronically painful situations (tendinopathy/tendinosis), in the synovial tissue of patients with rheumatoid arthritis and osteoarthritis, and in the mucosa of ulcerative colitis patients. There is evidence of both acetylcholine (ACh) production and a marked existence of muscarinic (M2) ACh receptors in these situations. The non-neuronal cholinergic system may be involved in the establishment of a 'cholinergic anti-inflammatory pathway' and in proliferative and tissue reorganisation processes via autocrine/paracrine effects. The new information obtained suggests that this system plays an important functional role in chronically painful tendons and in inflammatory conditions. The findings of such a system in various parts of the body, when taken together, show that not only should the classical neuronal cholinergic system be considered in discussion of the cholinergic influences in the body. Additionally, the production of ACh in local cells in the tissues represents an important extra supply of the transmitter. ACh effects can be obtained whether or not there is a cholinergic innervation in the tissue.
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Affiliation(s)
- Sture Forsgren
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, SE-901 87 Umeå, Sweden.
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Abstract
Overuse tendinopathy remains a major clinical burden for sports medicine and general practitioners. Recent studies have highlighted the role of sensory and autonomic nerves in generating or perpetuating the symptoms and tissue abnormalities associated with tendinopathy. We outline the neuroanatomy and potential roles of nerves and associated neuropeptides in tendinopathy. In addition, intriguing new data is reviewed which suggests that there may be a substantial intrinsic source of neuropeptides within tendons - namely, the tenocytes themselves. The potential roles of Substance P and mast cells are highlighted in particular. We discuss the implications for conservative management including sclerosing injections and exercise training.
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Affiliation(s)
- Alexander Scott
- Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, Canada.
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Abstract
Tendinopathy is a common clinical problem with athletes and in many occupational settings. Tendinopathy can occur in any tendon, often near its insertion or enthesis where there is an area of stress concentration, and is directly related to the volume of repetitive load to which the tendon is exposed. Recent studies indicate tendinopathy is more likely to occur in situations that increase the "dose" of load to the tendon enthesis - including increased activity, weight, advancing age, and genetic factors. The cells in tendinopathic tendon are rounder, more numerous, and show evidence of oxidative damage and more apoptosis. These cells also produce a matrix that is thicker and weaker with more water, more immature and cartilage-like matrix proteins, and less organization. There is now evidence of a population of regenerating stem cells within tendon. These studies suggest prevention of tendinopathy should be directed at reducing the volume of repetitive loads to below that which induces oxidative-induced apoptosis and cartilage-like genes. The management strategies might involve agents or cells that induce tendon stem cell proliferation, repair and restoration of matrix integrity.
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VEGF expression in patellar tendinopathy: a preliminary study. Clin Orthop Relat Res 2008; 466:1598-604. [PMID: 18459027 PMCID: PMC2505256 DOI: 10.1007/s11999-008-0272-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Accepted: 04/11/2008] [Indexed: 01/31/2023]
Abstract
Vascular function and angiogenesis are regulated by vascular endothelial growth factor-A (VEGF). The purpose of this preliminary study was to address the following questions: Is VEGF expression in the patellar tendon more prevalent in patients with patellar tendinopathy than in individuals with normal, pain-free patellar tendons? Which cell populations express VEGF in normal and tendinopathic tendon? Is there a difference in symptom duration between VEGF+ and VEGF- tendons? We collected patellar tendon tissue from 22 patients undergoing open débridement of the patellar tendon and from 10 patients undergoing intramedullary nailing of the tibia. VEGF expression was assessed immunohistochemically. Relevant inflammatory and repair cell types were immunolabeled. VEGF expression was absent from control tendons, but was present in a subset of patients with histopathological evidence of angiofibroblastic tendinosis. VEGF was expressed in the intimal layer of tendon vessels, but was absent in other cell types. Patients demonstrating VEGF expression in the patellar tendon had a shorter symptom duration (12 +/- 7.8 months) than patients with no detectable VEGF (32.8 +/- 23.5 months). VEGF may contribute to the vascular hyperplasia that is a cardinal feature of symptomatic tendinosis, particularly in cases with more recent onset.
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Danielson P, Andersson G, Alfredson H, Forsgren S. Marked sympathetic component in the perivascular innervation of the dorsal paratendinous tissue of the patellar tendon in arthroscopically treated tendinosis patients. Knee Surg Sports Traumatol Arthrosc 2008; 16:621-6. [PMID: 18418576 DOI: 10.1007/s00167-008-0530-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 03/14/2008] [Indexed: 01/04/2023]
Abstract
During the recent years, a few studies have shed new light on the innervation patterns of the human patellar tendon, but the area of the loose paratendinous connective tissue dorsal to the proximal tendon proper has yet not been investigated. That is a drawback, since this is the area targeted in promising treatment regimens of chronic painful patellar tendinosis, namely sclerosing Polidocanol injection therapy, and a new surgical method conforming to ultrasound and color Doppler guided arthroscopic shaving, directed at neovessels found in the region. The present study thus aimed at investigating the paratendinous area dorsal to the proximal patellar tendon proper in seven patients being operated for tendinosis. Biopsies were collected through the new arthroscopic technique, approaching the tendon from the dorsal side. Samples were investigated using immunohistochemistry with antibodies delineating general (PGP 9.5), sensory (SP/CGRP), and sympathetic (TH/NPY) nerve patterns, and also antibodies against alpha1- and alpha2A-adrenoreceptors. Both small and large blood vessels had a marked perivascular innervation (PGP 9.5). Surprisingly, this perivascular innervation was found only to a very limited extent to correspond to sensory nerves, while there were marked immunoreactions for sympathetic markers. Adrenoreceptor immunoreactions frequently occurred in blood vessel walls. In conclusion, this study demonstrates, for the first time, the innervation patterns of the area dorsal to the patellar tendon in man. It shows that the area investigated is under marked influence by the sympathetic nervous system. Thus, sympathetic effects are likely to occur for blood vessels of the area, which is interesting since color Doppler has revealed that vessels of this area ("neovessels") display a pathologically high blood flow in tendinosis. The findings are discussed in relation to aspects of vascular regulation, and to pain symptoms of tendinosis.
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Affiliation(s)
- Patrik Danielson
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, 901 87, Umeå, Sweden.
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Andersson G, Danielson P, Alfredson H, Forsgren S. Presence of substance P and the neurokinin-1 receptor in tenocytes of the human Achilles tendon. ACTA ACUST UNITED AC 2008; 150:81-7. [PMID: 18394729 DOI: 10.1016/j.regpep.2008.02.005] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Revised: 01/31/2008] [Accepted: 02/07/2008] [Indexed: 11/19/2022]
Abstract
Nerve signal substances, such as the tachykinin substance P (SP), may be involved in the changes that occur in response to tendinopathy (tendinosis). It is previously known that the level of SP innervation within tendon tissue is limited, but results of experimental studies have suggested that SP may have stimulatory, angiogenetic and healing effects in injured tendons. Therefore, it would be of interest to know if there is a local SP-supply in tendon tissue. In the present study, the patterns of expression of SP and its preferred receptor, the neurokinin-1 receptor (NK-1 R), in normal and tendinosis human Achilles tendons were analyzed by use of both immunohistochemistry and in situ hybridization. We found that there was expression of SP mRNA in tenocytes, and that tenocytes showed expression of NK-1 R at protein as well as mRNA levels. The observations concerning both SP and NK-1 R were most evident for tenocytes in tendinosis tendons. Our findings suggest that SP is produced in tendinosis tendons, and furthermore that SP has marked effects on the tenocytes via the NK-1 R. It cannot be excluded that the SP effects are of importance concerning the processes of reorganization and healing that occur for tendon tissue in tendinosis. In conclusion, it appears as if SPergic autocrine/paracrine effects occur in tendon tissue during the processes of tendinosis, hitherto unknown effects for human tendons.
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Affiliation(s)
- Gustav Andersson
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, SE-901 87 Umeå, Sweden.
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Danielson P, Alfredson H, Forsgren S. In situ hybridization studies confirming recent findings of the existence of a local nonneuronal catecholamine production in human patellar tendinosis. Microsc Res Tech 2007; 70:908-11. [PMID: 17661370 DOI: 10.1002/jemt.20495] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We have in recent studies presented unexpected immunohistochemical evidence favoring the existence of a local production of catecholamines, and an occurrence of adrenergic receptors on the tendon cells (tenocytes), in the human patellar tendon. This was particularly noticed for tendons from patients suffering from tendinosis (chronic tendon pain), which has led us to propose an involvement of this autocrine/paracrine system in the development of tendinosis, especially since catecholamines have been reported to be modulators of tissue remodeling and pain processes. However, the findings concerning catecholamine production have so far only been noted at the level of protein detection, and for this reason, the aim of the present study was to confirm the previous immunohistochemical results by using in situ hybridization (ISH) technique. A ssDNA probe detecting human mRNA for the catecholamine-synthesizing enzyme tyrosine hydroxylase (TH) was applied. The ISH results revealed that there were clear reactions indicating the existence of mRNA for TH in tenocytes of tendinosis specimens. It was generally noted that disfigured tenocytes were the ones with the most distinct reactions, while normally looking tenocytes hardly displayed any reactions at all. In conclusion, this study presents the first evidence at the mRNA level of the existence of a local nonneuronal production of catecholamines in human patellar tendon tissue. The findings add to recent observations of the occurrence of a local production in tendons of signal substances traditionally related to neurons.
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Affiliation(s)
- Patrik Danielson
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, SE-901 87 Umeå, Sweden.
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Andersson G, Danielson P, Alfredson H, Forsgren S. Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2007; 15:1272-9. [PMID: 17604979 DOI: 10.1007/s00167-007-0364-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 05/07/2007] [Indexed: 11/29/2022]
Abstract
Ultrasound and Doppler examination has shown high blood flow-neovascularisation inside and outside the ventral Achilles tendon in chronic painful tendinosis, but not in pain-free normal Achilles tendons. In patients with Achilles tendinosis, injections with the sclerosing substance polidocanol, targeting the areas with increased blood flow, have been demonstrated to give pain relief. A drawback when interpreting these findings is the fact that the pattern of nerve supply in the target area, i.e. the ventral area of the tendon, is so far unknown. In this study, therefore, tissue specimens from this area, obtained during surgical treatment of patients with chronic painful midportion Achilles tendinosis, were examined. In the examined area, containing loose connective tissue, the general finding was a presence of large and small arteries and nerve fascicles. The nerve fascicles were distinguished in sections processed for the pan-neural marker protein gene-product 9.5. The nerve fascicles contain sensory nerve fibers, as shown via staining for the sensory markers substance P (SP) and calcitonin gene-related peptide, and sympathetic nerve fibers as seen via processing for tyrosine hydroxylase. In addition, there were immunoreactions for the SP-preferred receptor, the neurokinin-1 receptor, in blood vessel walls and nerve fascicles. Some of the blood vessels were supplied by an extensive peri-vascular innervation, sympathetic nerve fibers being a distinct component of this innervation. There was also a marked occurrence of immunoreactions for the alpha1-adrenoreceptor in arterial walls as well as in the nerve fascicles. Altogether, these findings suggest that the area investigated is under marked influence by the nervous system, including sympathetic and sensory components. Thus, sympathetic/sensory influences may be involved in the pain mechanisms from this area. In conclusion, the nerve-related characteristics of the area targeted by the polidicanol injection treatment for Achilles tendinosis, are shown here for the first time.
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Affiliation(s)
- Gustav Andersson
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, 901 87, Umeå, Sweden
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