Temporal effect of in vivo tendon fatigue loading on the apoptotic response explained in the context of number of fatigue loading cycles and initial damage parameters

Successive tendon injury in an in vivo rat overload model induces early damage and acute healing responses

Introduction: Tendinopathy is a degenerative condition resulting from tendons experiencing abnormal levels of multi-scale damage over time, impairing their ability to repair. However, the damage markers associated with the initiation of tendinopathy are poorly understood, as the disease is largely characterized by end-stage clinical phenotypes. Thus, this study aimed to evaluate the acute tendon responses to successive fatigue bouts of tendon overload using an in vivo passive ankle dorsiflexion system. Methods: Sprague Dawley female rats underwent fatigue overloading to their Achilles tendons for 1, 2, or 3 loading bouts, with two days of rest in between each bout. Mechanical, structural, and biological assays were performed on tendon samples to evaluate the innate acute healing response to overload injuries. Results: Here, we show that fatigue overloading significantly reduces in vivo functional and mechanical properties, with reductions in hysteresis, peak stress, and loading and unloading moduli. Multi-scale structural damage on cellular, fibril, and fiber levels demonstrated accumulated micro-damage that may have induced a reparative response to successive loading bouts. The acute healing response resulted in alterations in matrix turnover and early inflammatory upregulations associated with matrix remodeling and acute responses to injuries. Discussion: This work demonstrates accumulated damage and acute changes to the tendon healing response caused by successive bouts of in vivo fatigue overloads. These results provide the avenue for future investigations of long-term evaluations of tendon overload in the context of tendinopathy.

A passive ankle dorsiflexion testing system to assess mechanobiological and structural response to cyclic loading in rat Achilles tendon

Tendinopathy is thought to be caused by repeated overload of the tendon with insufficient recovery time, leading to an inadequate healing response and incomplete recovery of preinjury material strength and function. The etiology of tendinopathy induced by mechanical load is being explored with a variety of mechanical load scenarios in small animals. This study establishes a testing system that applies passive ankle dorsiflexion to a rat hindlimb, estimates the force applied to the tendon during cyclic loading and enables the assessment of subsequent structural and biological changes. We demonstrated that the system had no drift in the applied angle, and the registered maximum angle and torque inputs and outputs were consistent between tests. We showed that cyclic loading decreased hysteresis and loading and unloading moduli with increasing cycles applied to the tendon. Histology showed gross changes to tendon structure. This work establishes a system for passively loading the rat Achilles tendon in-vivo in a physiological manner, facilitating future studies that will explore how mechanics, structure, and biology are altered by mechanical repetitive loading.

Establishing in vivo and ex vivo chick embryo models to investigate fetal tendon healing

Injured adult tendons heal fibrotically and possess high re-injury rates, whereas fetal tendons appear to heal scarlessly. However, knowledge of fetal tendon wound healing is limited due in part to the need for an accessible animal model. Here, we developed and characterized an in vivo and ex vivo chick embryo tendon model to study fetal tendon healing. In both models, injury sites filled rapidly with cells and extracellular matrix during healing, with wound closure occurring faster in vivo. Tendons injured at an earlier embryonic stage improved mechanical properties to levels similar to non-injured controls, whereas tendons injured at a later embryonic stage did not. Expression levels of tendon phenotype markers, collagens, collagen crosslinking regulators, matrix metalloproteinases, and pro-inflammatory mediators exhibited embryonic stage-dependent trends during healing. Apoptosis occurred during healing, but ex vivo tendons exhibited higher levels of apoptosis than tendons in vivo. Future studies will use these in vivo and ex vivo chick embryo tendon injury models to elucidate mechanisms of stage-specific fetal tendon healing to inform the development of therapeutic approaches to regeneratively heal adult tendons.

An Adolescent Murine In Vivo Anterior Cruciate Ligament Overuse Injury Model

BACKGROUND

Overuse ligament and tendon injuries are prevalent among recreational and competitive adolescent athletes. In vitro studies of the ligament and tendon suggest that mechanical overuse musculoskeletal injuries begin with collagen triple-helix unraveling, leading to collagen laxity and matrix damage. However, there are little in vivo data concerning this mechanism or the physiomechanical response to collagen disruption, particularly regarding the anterior cruciate ligament (ACL).

PURPOSE

To develop and validate a novel in vivo animal model for investigating the physiomechanical response to ACL collagen matrix damage accumulation and propagation in the ACL midsubstance, fibrocartilaginous entheses, and subchondral bone.

STUDY DESIGN

Controlled laboratory study.

METHODS

C57BL/6J adolescent inbred mice underwent 3 moderate to strenuous ACL fatigue loading sessions with a 72-hour recovery between sessions. Before each session, randomly selected subsets of mice (n = 12) were euthanized for quantifying collagen matrix damage (percent collagen unraveling) and ACL mechanics (strength and stiffness). This enabled the quasi-longitudinal assessment of collagen matrix damage accrual and whole tissue mechanical property changes across fatigue sessions. Additionally, all cyclic loading data were quantified to evaluate changes in knee mechanics (stiffness and hysteresis) across fatigue sessions.

RESULTS

Moderate to strenuous fatigue loading across 3 sessions led to a 24% weaker (P = .07) and 35% less stiff (P < .01) ACL compared with nonloaded controls. The unraveled collagen densities within the fatigued ACL and entheseal matrices after the second and third sessions were 38% (P < .01) and 15% (P = .02) higher compared with the nonloaded controls.

CONCLUSION

This study confirmed the hypothesis that in vivo ACL collagen matrix damage increases with tissue fatigue sessions, adversely impacting ACL mechanical properties. Moreover, the in vivo ACL findings were consistent with in vitro overloading research in humans.

CLINICAL RELEVANCE

The outcomes from this study support the use of this model for investigating ACL overuse injuries.

Adolescent Marathon Training: Prospective Evaluation of Musculotendinous Changes During a 6-Month Endurance Running Program

OBJECTIVES

Assess changes in lower extremity musculotendinous thickness, tissue echogenicity, and muscle pennation angles among adolescent runners enrolled in a 6-month distance running program.

METHODS

We conducted prospective evaluations of adolescent runners' lower extremity musculotendinous changes at three timepoints (baseline, 3 months, and 6 months) throughout a progressive marathon training program. Two experienced researchers used an established protocol to obtain short- and long-axis ultrasound images of the medial gastrocnemius, tibialis anterior, flexor digitorum brevis, abductor hallicus, and Achilles and patellar tendons. ImageJ software was used to calculate musculotendinous thickness and echogenicity for all structures, and fiber pennation angles for the ankle extrinsic muscles. Repeated measures within-subject analyses of variance were conducted to assess the effect of endurance training on ultrasound-derived measures.

RESULTS

We assessed 11 runners (40.7% of eligible runners; 6F, 5M; age: 16 ± 1 years; running experience: 3 ± 2 years) who remained injury-free and completed all ultrasound evaluation timepoints. Medial gastrocnemius muscle (F_2,20  = 3.48, P = .05), tibialis anterior muscle (F_2,20  = 7.36, P = .004), and Achilles tendon (F_2,20  = 3.58, P = .05) thickness significantly increased over time. Echogenicity measures significantly decreased in all muscles (P-range: <.001-.004), and increased for the patellar tendon (P < .001) during training. Muscle fiber pennation angles significantly increased for ankle extrinsic muscles (P < .001).

CONCLUSIONS

Adolescent runners' extrinsic foot and ankle muscles increased in volume and decreased in echogenicity, attributed to favorable distance training adaptations across the 6-month timeframe. We noted tendon thickening without concomitantly increased echogenicity, signaling intrasubstance tendon remodeling in response to escalating distance.

Glycosaminoglycans modulate microscale mechanics and viscoelasticity in fatigue injured tendons

Tendinopathies are common injuries that typically occur from overuse and fatigue. Treatments target late-stage symptoms with limited success, leading to high rates of reinjury. Early intervention could halt tendinopathy progression to rupture but requires a better understanding of the biomechanical environment associated with early-stage disease. While fatigue injured tendons are further damaged by exercise that is initiated immediately after onset of injury, exercise that is initiated after a brief delay promotes repair. Similar macroscale mechanical properties and collagen damage throughout this delay period suggests that microscale, non-collagenous matrix changes after fatigue injury modulate tendon mechanotransduction and shifts the exercise response from detrimental to reparative. Glycosaminoglycans (GAGs) and proteoglycans (PGs) are increased during chronic tendinopathy, but their role in early-stage disease is unknown. We hypothesized that increased GAGs from fatigue injury modulate viscoelasticity and microscale strains to enable repair from exercise. Various GAG types were increased in the weeks after onset of fatigue injury in the extracellular and pericellular matrices of rat patellar tendons. Enzymatic removal of GAGs from these fatigued tendons increased microscale shear strain, suggesting that GAGs modulate the cell microenvironment after fatigue injury. GAG removal decreased dynamic modulus in the toe region and decreased loss tangent in the linear region of the stress-strain curve in fatigued tendons, suggesting the GAG increase modulates tendon multiscale mechanics and viscoelasticity during fiber uncrimping and fibril sliding and strain transfer. GAGs may influence repair in response to exercise and could serve as a therapeutic target for tendinopathy.

Development and application of a novel in vivo overload model of the Achilles tendon in rat

Repetitive overload is a primary factor in tendon injury, causing progressive accumulation of matrix damage concurrent with a cellular response. However, it remains unclear how these events occur at the initial stages of the disease, making it difficult to identify appropriate treatment approaches. Here, we describe the development of a new model to cyclically load the Achilles tendon (AT) of rats in vivo and investigate the initial structural and cellular responses. The model utilizes controlled dorsiflexion of the ankle joint applied near maximal dorsiflexion, for 10,000 cycles at 3 Hz. Animals were subjected to a single bout of in vivo loading under anaesthesia, and either culled immediately (without recovery from anaesthesia), or 48 h or 4-weeks post-loading. Macro strains were assessed in cadavers, whilst tendon specific microdamage was assessed through collagen-hybridizing peptide (CHP) immunohistochemistry which highlighted a significant rise in CHP staining in loaded ATs compared to contralateral controls, indicating an accumulation of overload-induced damage. Staining for pro-inflammatory mediators (IL-6 and COX-2) and matrix degradation markers (MMP-3 and -13) also suggests an initial cellular response to overload. Model validation confirmed our approach was able to explore early overload-induced damage within the AT, with microdamage present and no evidence of broader musculoskeletal damage. The new model may be implemented to map the progression of tendinopathy in the AT, and thus study potential therapeutic interventions.

Review of human supraspinatus tendon mechanics. Part I: fatigue damage accumulation and failure

Repetitive stress injuries to the rotator cuff, and particularly the supraspinatus tendon (SST), are highly prevalent and debilitating. These injuries typically occur through the application of cyclic load below the threshold necessary to cause acute tears, leading to accumulation of incremental damage that exceeds the body's ability to heal, resulting in decreased mechanical strength and increased risk of frank rupture at lower loads. Consistent progression of fatigue damage across multiple model systems suggests a generalized tendon response to overuse. This finding may allow for interventions before gross injury of the SST occurs. Further research into the human SST response to fatigue loading is necessary to characterize the fatigue life of the tendon, which will help determine the frequency, duration, and magnitude of load spectra the SST may experience before injury. Future studies may allow in vivo SST strain analysis during specific activities, generation of a human SST stress-cycle curve, and characterization of damage and repair related to repetitive tasks.

Sonographic Screening of Distance Runners for the Development of Future Achilles and Patellar Tendon Pain

OBJECTIVE

The 2 primary aims of this study were to identify ultrasonographic tendon abnormalities in asymptomatic runners and to examine the likelihood of developing pain in runners with ultrasound abnormalities compared with those without abnormalities.

DESIGN

Longitudinal, prospective cohort study.

SETTING

2019 Salt Lake City Marathon.

PARTICIPANTS

Recreational half-marathon and full-marathon runners.

ASSESSMENT OF RISK FACTORS

The Achilles and patellar tendons of asymptomatic runners were examined with ultrasound imaging before a running event. Runners were monitored for self-reported outcomes of pain in the examined tendons at 1, 3, 6, and 12 months after the event.

MAIN OUTCOME MEASURES

Development of pain based on the presence of asymptomatic tendon abnormalities.

RESULTS

One hundred thirty-eight runners (36.2 ± 12.0 years, 49.3% men, and 31.2% full-marathon runners) were included. Ultrasound abnormalities of the Achilles and patellar tendons were identified in 24.6% and 39.1% of the runners before the race, respectively. Ultrasound abnormalities were significantly associated with approximately a 3-fold increase [hazard ratio (HR) = 2.55, P = 0.004] in the hazard of developing pain in the Achilles tendon and patellar tendon (HR = 1.67, P = 0.042) over the year after the race. Positive and negative predictive values of developing pain over the year were 34.1% and 87.2%, respectively, for abnormal findings in the Achilles tendon, and 22.9% and 85.0%, respectively, for the patellar tendon.

CONCLUSIONS

The presence of ultrasonographic abnormalities is associated with increased development of pain in the Achilles and patellar tendons within 1 year of a marathon or half marathon.

The role of the tendon ECM in mechanotransduction: disruption and repair following overuse

Purpose: Tendon overuse injuries are prevalent conditions with limited therapeutic options to halt disease progression. The specialized extracellular matrix (ECM) both enables joint function and mediates mechanical signals to tendon cells, driving biological responses to exercise or injury. With overuse, tendon ECM composition and structure changes at multiple scales, disrupting mechanotransduction and resulting in inadequate repair and disease progression. This review highlights the multiscale ECM changes that occur with tendon overuse and corresponding effects on cell-matrix interactions and cellular response to load.Results: Different functional joint requirements and tendon types experience a wide range of loading profiles, creating varied downstream mechanical stimuli. Distinct ECM structure and mechanical properties within the fascicle matrix, interfascicle matrix, and enthesis and their varied disruption with overuse are considered. The pericellular matrix (PCM) comprising the microscale tendon cell environment has a unique composition that changes with overuse injury and exercise, suggesting an important role in mechanotransduction and promoting repair. Cell-matrix interactions are mediated by structures including cilia, integrins, connexins and cytoskeleton that signal downstream homeostasis, adaptation, or repair. ECM disruption with tendon overuse may cause altered mechanical loading and cell-matrix interactions, resulting in mechanobiological understimulation, apoptosis, and ineffective repair. Current interventions to promote repair of tendon overuse injuries including exercise, targeting cell signaling, and modulating inflammation are considered.Conclusion: Future therapeutics should be assessed with regard of their effects on multiscale mechanotransduction in addition to joint function, with consideration of the central role of ECM.

A multiscale study of morphological changes in tendons following repeated cyclic loading

The response of white New Zealand rabbit Achilles tendons to load was assessed using mechanical measures and confocal arthroscopy (CA). The progression of fatigue-loading-induced damage of the macro- (tenocyte morphology, fiber anisotropy and waviness), as well as the mechanical profile, were assessed within the same non-viable intact tendon in response to prolonged cyclic and static loading (up to four hours) at different strain levels (3%, 6% and 9%). Strain-mediated repeated loading induced a significant decline in mechanical function (p < 0.05) with increased strain and cycles. Mechanical and structural resilience was lost with repeated loading (p < 0.05) at macroscales. The lengthening of D-periodicity correlated strongly with the overall tendon mechanical changes and loss of spindle shape in tenocytes. This is the first study to provide a clear concurrent assessment of form (morphology) and function (mechanics) of tendons undergoing different strain-mediated repeated loading at multiple-scale assessments. This study identifies a variety of multiscale properties that may contribute to the understanding of mechanisms of tendon pathology.

Ultrasound evaluation of the patellar tendon and Achilles tendon and its association with future pain in distance runners

Objectives: To examine whether asymptomatic ultrasonographic abnormalities in the Achilles and patellar tendons in runners are associated with an increased risk of pain development.Methods: This is a longitudinal, prospective cohort study with 139 runners recruited at a half and full marathon race. Ultrasound examination of the Achilles and patellar tendons was performed bilaterally the day prior to the race. Self-reported injury data were collected at 1, 3, 6 and 12 months. 104 (74.8%) runners were included in the data analysis.Results: Ultrasonographic tendon abnormalities were found in 24.1% of the Achilles and in 23.1% of the patellar tendons prior to the race. Runners with tendon abnormality were 2-3 times more likely to develop pain within 12 months than those without (relative risk = 3.14, p = 0.010 for Achilles; relative risk = 2.52, p = 0.008 for patellar tendon). After adjusting for gender, age, years of running, average miles per week of running over a year, and pre-race pain, runners with ultrasound abnormality were about 3 times (hazard ratio = 2.89, p = 0.039 for Achilles; hazard ratio = 2.73, p = 0.030 for patellar tendon) more likely to develop pain after the race. Tendon delamination was most strongly associated with pain in both the Achilles (relative risk = 6.00; p = 0.001) and patellar tendons (relative risk = 3.81; p = 0.001).Conclusions: Structural changes in asymptomatic tendons were found in almost 25% of runners. Presence of structural changes was associated with increased development of Achilles and patellar tendon pain within one year.

Tendinopathy and tendon material response to load: What we can learn from small animal studies

Tendinopathy is a debilitating disease that causes as much as 30% of all musculoskeletal consultations. Existing treatments for tendinopathy have variable efficacy, possibly due to incomplete characterization of the underlying pathophysiology. Mechanical load can have both beneficial and detrimental effects on tendon, as the overall tendon response depends on the degree, frequency, timing, and magnitude of the load. The clinical continuum model of tendinopathy offers insight into the late stages of tendinopathy, but it does not capture the subclinical tendinopathic changes that begin before pain or loss of function. Small animal models that use high tendon loading to mimic human tendinopathy may be able to fill this knowledge gap. The goal of this review is to summarize the insights from in-vivo animal studies of mechanically-induced tendinopathy and higher loading regimens into the mechanical, microstructural, and biological features that help characterize the continuum between normal tendon and tendinopathy. STATEMENT OF SIGNIFICANCE: This review summarizes the insights gained from in-vivo animal studies of mechanically-induced tendinopathy by evaluating the effect high loading regimens have on the mechanical, structural, and biological features of tendinopathy. A better understanding of the interplay between these realms could lead to improved patient management, especially in the presence of painful tendon.

Tendon Extracellular Matrix Assembly, Maintenance and Dysregulation Throughout Life

In his Lissner Award medal lecture in 2000, Stephen Cowin asked the question: "How is a tissue built?" It is not a new question, but it remains as relevant today as it did when it was asked 20 years ago. In fact, research on the organization and development of tissue structure has been a primary focus of tendon and ligament research for over two centuries. The tendon extracellular matrix (ECM) is critical to overall tissue function; it gives the tissue its unique mechanical properties, exhibiting complex non-linear responses, viscoelasticity and flow mechanisms, excellent energy storage and fatigue resistance. This matrix also creates a unique microenvironment for resident cells, allowing cells to maintain their phenotype and translate mechanical and chemical signals into biological responses. Importantly, this architecture is constantly remodeled by local cell populations in response to changing biochemical (systemic and local disease or injury) and mechanical (exercise, disuse, and overuse) stimuli. Here, we review the current understanding of matrix remodeling throughout life, focusing on formation and assembly during the postnatal period, maintenance and homeostasis during adulthood, and changes to homeostasis in natural aging. We also discuss advances in model systems and novel tools for studying collagen and non-collagenous matrix remodeling throughout life, and finally conclude by identifying key questions that have yet to be answered.

Platelet-Rich Plasma Therapy in the Treatment of Diseases Associated with Orthopedic Injuries

Platelet-rich plasma (PRP) is an autologous platelet concentrate prepared from the whole blood that is activated to release growth factors (GFs) and cytokines and has been shown to have the potential capacity to reduce inflammation and improve tissue anabolism for regeneration. The use of PRP provides a potential for repair due to its abundant GFs and cytokines, which are key in initiating and modulating regenerative microenvironments for soft and hard tissues. Among outpatients, orthopedic injuries are common and include bone defects, ligament injury, enthesopathy, musculoskeletal injury, peripheral nerve injury, chronic nonhealing wounds, articular cartilage lesions, and osteoarthritis, which are caused by trauma, sport-related or other types of trauma, or tumor resection. Surgical intervention is often required to treat these injuries. However, for numerous reasons regarding limited regeneration capacity and insufficient blood supply of the defect region, these treatments commonly result in unsatisfactory outcomes, and follow-up treatment is challenging. The aim of the present review is to explore future research in the field of PRP therapy in the treatment of diseases associated with orthopedic injuries. Impact statement In recent years, platelet-rich plasma (PRP) has become widely used in the treatment of diseases associated with orthopedic injuries, and the results of numerous studies are encouraging. Due to diseases associated with orthopedic injuries being common in clinics, as a conservative treatment, more and more doctors and patients are more likely to accept PRP. Importantly, PRP is a biological product of autologous blood that is obtained by a centrifugation procedure to enrich platelets from whole blood, resulting in few complications, such as negligible immunogenicity from an autologous source, and it is also simple to produce through an efficient and cost-effective method in a sterile environment. However, the applicability, advantages, and disadvantages of PRP therapy have not yet been fully elucidated. The aim of the present review is to explore future research in the field of PRP therapy in the treatment of diseases associated with orthopedic injuries, as well as to provide references for clinics.

High cholesterol induces apoptosis and autophagy through the ROS-activated AKT/FOXO1 pathway in tendon-derived stem cells

BACKGROUND

Hypercholesterolemia increases the risk of tendon pain and tendon rupture. Tendon-derived stem cells (TDSCs) play a vital role in the development of tendinopathy. Our previous research found that high cholesterol inhibits tendon-related gene expression in TDSCs. Whether high cholesterol has other biological effects on TDSCs remains unknown.

METHODS

TDSCs isolated from female SD rats were exposed to 10 mg/dL cholesterol for 24 h. Then, cell apoptosis was assessed using flow cytometry and fluorescence microscope. RFP-GFP-LC3 adenovirus transfection was used for measuring autophagy. Signaling transduction was measured by immunofluorescence and immunoblotting. In addition, Achilles tendons from ApoE -/- mice fed with a high-fat diet were histologically assessed using HE staining and immunohistochemistry.

RESULTS

In this work, we verified that 10 mg/dL cholesterol suppressed cell proliferation and migration and induced G0/G1 phase arrest. Additionally, cholesterol induced apoptosis and autophagy simultaneously in TDSCs. Apoptosis induction was related to increased expression of cleaved caspase-3 and BAX and decreased expression of Bcl-xL. The occurrence of autophagic flux and accumulation of LC3-II demonstrated the induction of autophagy by cholesterol. Compared with the effects of cholesterol treatment alone, the autophagy inhibitor 3-methyladenine (3-MA) enhanced apoptosis, while the apoptosis inhibitor Z-VAD-FMK diminished cholesterol-induced autophagy. Moreover, cholesterol triggered reactive oxygen species (ROS) generation and activated the AKT/FOXO1 pathway, while the ROS scavenger NAC blocked cholesterol-induced activation of the AKT/FOXO1 pathway. NAC and the FOXO1 inhibitor AS1842856 rescued the apoptosis and autophagy induced by cholesterol. Finally, high cholesterol elevated the expression of cleaved caspase-3, Bax, LC3-II, and FOXO1 in vivo.

CONCLUSION

The present study indicated that high cholesterol induced apoptosis and autophagy through ROS-activated AKT/FOXO1 signaling in TDSCs, providing new insights into the mechanism of hypercholesterolemia-induced tendinopathy. High cholesterol induces apoptosis and autophagy through the ROS-activated AKT/FOXO1 pathway in tendon-derived stem cells.

Mechanical stress-induced cell death in breast cancer cells

Providing an external mechanical stress to cancer cells seems to be an effective approach to treat cancer locally. Numbers of reports on cancer cell death subjected to mechanical stress loading are increasing, but they are more focused on apoptosis. Inducing necrosis is also important in attracting more immune cells to the cancer site via the release of danger-associated molecular patterns from cancer cells. Here we applied dynamic compression to breast cancer cells with a low frequency (0.1-30 Hz) and for a short duration (30-300 s) and they resulted in a mixed mode of apoptosis and necrosis dominant with necrotic cell death, which we call mechanical stress-induced cell death (MSICD). The necrotic cell damage of mechanically treated breast cancer cells increased in a force-dependent and time-dependent manner while a trend of frequency-independent MSICD was observed.

Multiscale mechanisms of tendon fatigue damage progression and severity are strain and cycle dependent

Tendinopathies are common chronic injuries that occur when damage accumulation caused by sub-rupture fatigue loading outpaces repair. Studies have linked fatigue loading with various mechanical, structural, and biological changes associated with pathology. However, the multiscale progression of damage accumulation with respect to area, severity and the distinct contributions of strain level and number of cycles has not been fully elucidated. The objective of this study was to investigate multiscale mechanisms underlying fatigue damage accumulation and their effect on the cellular environment. Using an in situ model in rat tail tendon (RTT), fatigue loading was applied at various strains and cycle numbers to induce fatigue damage. Pre- and post- fatigue diagnostic mechanical testing, second harmonic generation (SHG) imaging, and transmission electron microscope (TEM) imaging were used to investigate extracellular and cellular damage modes at multiple scales. Fatigue loading at strains at or below 1.0% resulted in no significant changes in SHG damage area or severity and no changes in collagen fibril or cell morphology compared with controls. Fatigue loading at strains above 1.5% resulted in greater mechanical changes correlated with increased damage area measured by SHG and collagenous damage observed by TEM. Increased cycles at high strain further altered mechanical properties, increased structural damage severity (but not area), and altered TEM collagen rupture patterns. Cell morphology was similarly progressively affected with increased strain and cycle number. These damage mechanisms that may trigger degenerative changes characteristic of tendinopathy could be targeted as a part of prevention or therapy.

Promoting effective tendon healing and remodeling

Daily activities subject our tendons to accumulation of sub-rupture fatigue injury which can lead to tendon rupture. Consequently, tendinopathies account for over 30% of musculoskeletal consultations. We adopted a multidisciplinary approach to determine the role of the extracellular matrix (ECM) in the pathogenesis of tendinopathy and impaired healing of ruptured tendons. We have been investigating three main areas: (i) the pathogenesis of tendon degeneration; (ii) approaches to promoting remodeling of sub-rupture fatigue injuries; and the (iii) role of the ECM in promoting scarless tendon healing. In this Kappa Delta Young Investigator award paper, we describe the key discoveries made in each of our three research areas of focus. Briefly, we discovered that sub-rupture fatigue damage can accumulate from just one bout of fatigue loading. Furthermore, any attempt to repair the fatigue damage diminishes as the severity of induced damage increases. We have utilized exercise to develop animal models of exercise-led degeneration and exercise-led repair of sub-rupture fatigue damage injuries, wherein underlying mechanisms can be uncovered, thereby overcoming a major hurdle to development of therapeutics. Since damage accumulation ultimately leads to rupture that is characterized by formation of a mechanically inferior scar, we have used the MRL/MpJ mouse to evaluate the role of the systemic environment and the local tendon environment in driving regeneration to identify new therapeutic pathways to promote scarless healing. Our data suggests that the therapeutic potential of the MRL/MpJ provisional ECM should be further explored as it may harness biological and structural mechanisms to promote scarless healing. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3115-3124, 2018.

Load transfer, damage, and failure in ligaments and tendons

The function of ligaments and tendons is to support and transmit loads applied to the musculoskeletal system. These tissues are often able to perform their function for many decades; however, connective tissue disease and injury can compromise ligament and tendon integrity. A range of protein and non-protein constituents, combined in a complex structural hierarchy from the collagen molecule to the tissue and covering nanometer to centimeter length scales, govern tissue function, and impart characteristic non-linear material behavior. This review summarizes the structure of ligaments and tendons, the roles of their constituent components for load transfer across the hierarchy of structure, and the current understanding of how damage occurs in these tissues. Disease and injury can alter the constituent make-up and structural organization of ligaments and tendons, affecting tissue function, while also providing insight to the role and interactions of individual constituents. The studies and techniques presented here have helped to understand the relationship between tissue constituents and the physical mechanisms (e.g., stretching, sliding) that govern material behavior at and between length scales. In recent years, new techniques have been developed to probe ever smaller length scales and may help to elucidate mechanisms of load transfer and damage and the molecular constituents involved in the in the earliest stages of ligament and tendon damage. A detailed understanding of load transfer and damage from the molecular to the tissue level may elucidate targets for the treatment of connective tissue diseases and inform practice to prevent and rehabilitate ligament and tendon injuries. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3093-3104, 2018.

Tendinopathy: Investigating the Intersection of Clinical and Animal Research to Identify Progress and Hurdles in the Field

Biological treatments, surgical interventions, and rehabilitation exercises have been successfully used to treat tendinopathy, but the development of effective treatments has been hindered by the lack of mechanistic data regarding the pathogenesis of the disease. While insightful, clinical studies are limited in their capacity to provide data regarding the pathogenesis of tendinopathies, emphasizing the value of animal models and cell culture studies to fill this essential gap in knowledge. Clinical pathological findings from imaging studies or histological analysis are not universal across patients with tendinopathy and have not been clearly associated with the onset of symptoms. There are several unresolved controversies, including the cellular changes that accompany the tendinopathic disease state and the role of inflammation. Additional research is needed to correlate the manifestations of the disease with its pathogenesis, with the goal of reaching a field-wide consensus on the pathology of the disease state. Such a consensus will allow standardized clinical practices to more effectively diagnose and treat tendinopathy.

Inhibition of apoptosis exacerbates fatigue-damage tendon injuries in an in vivo rat model

Tendinopathy is a common and progressive musculoskeletal disease. Increased apoptosis is an end-stage tendinopathy manifestation, but its contribution to the pathology of the disease is unknown. A previously established in vivo model of fatigue damage accumulation shows that increased apoptosis is correlated with the severity of induced tendon damage, even in early onset of the disease, supporting its implication in the pathogenesis of the disease. Consequently, this study aimed to determine: (1) whether apoptosis could be inhibited after fatigue damage and (2) whether its inhibition could lead to remodeling of the extracellular matrix (ECM) and pericellular matrix (PCM), to ultimately improve the mechanical properties of fatigue-damaged tendons. The working hypothesis was that, despite the low vascular nature of the tendon, apoptosis would be inhibited, prompting increased production of matrix proteins and restoring tendon mechanical properties. Rats received 2 or 5 d of systemic pan-caspase inhibitor (Q-VD-OPh) or dimethyl sulfoxide (DMSO) carrier control injections starting immediately prior to fatigue loading and were sacrificed at days 7 and 14 post-fatigue-loading. Systemic pan-caspase inhibition for 2 d led to a surprising increase in apoptosis, but inhibition for 5 d increased the population of live cells that could repair the fatigue damage. Further analysis of the 5 d group showed that effective inhibition led to an increased population of cells producing ECM and PCM proteins, although typically in conjunction with oxidative stress markers. Ultimately, inhibition of apoptosis led to further deterioration in mechanical properties of fatigue-damaged tendons.

A potential new role for myofibroblasts in remodeling of sub-rupture fatigue tendon injuries by exercise

Tendons are ineffective at repairing sub-rupture fatigue injuries. Accordingly, we evaluated whether an exercise protocol that we have previously found to decrease structural damage kinks in fatigue damaged tendons, leads to improvement in mechanical properties. We hypothesized that exercise that promotes repair of fatigue damage will decrease apoptosis and increase the population of myofibroblasts. Rat patellar tendons underwent in vivo fatigue loading for 500 or 7200 cycles. Animals resumed cage activity for 2-weeks, then either remained cage active or began treadmill running until sacrifice at 4- or 10-weeks post-fatigue loading. Exercise following fatigue damage increased the stiffness back towards naïve levels, decreased apoptosis and increased the population of myofibroblasts. Next, proteins associated with inhibition of apoptosis (Collagen VI) or activation of myofibroblast (pSmad 2/3, fibrillin, integrin subunits αV and α5) were evaluated. Data suggests that collagen VI may not be integral to inhibition of apoptosis in this context. Exercise increased pSmad 2/3 and fibrillin in the insertion region for the 7200-cycles group. In addition, exercise decreased integrin αV and increased integrin α5 in fatigue damaged tendons. Data suggests that a decrease in apoptosis and an increase in population of myofibroblasts may be integral to remodeling of fatigue damaged tendons.

Novel image analysis methods for quantification of in situ 3-D tendon cell and matrix strain

Macroscopic tendon loads modulate the cellular microenvironment leading to biological outcomes such as degeneration or repair. Previous studies have shown that damage accumulation and the phases of tendon healing are marked by significant changes in the extracellular matrix, but it remains unknown how mechanical forces of the extracellular matrix are translated to mechanotransduction pathways that ultimately drive the biological response. Our overarching hypothesis is that the unique relationship between extracellular matrix strain and cell deformation will dictate biological outcomes, prompting the need for quantitative methods to characterize the local strain environment. While 2-D methods have successfully calculated matrix strain and cell deformation, 3-D methods are necessary to capture the increased complexity that can arise due to high levels of anisotropy and out-of-plane motion, particularly in the disorganized, highly cellular, injured state. In this study, we validated the use of digital volume correlation methods to quantify 3-D matrix strain using images of naïve tendon cells, the collagen fiber matrix, and injured tendon cells. Additionally, naïve tendon cell images were used to develop novel methods for 3-D cell deformation and 3-D cell-matrix strain, which is defined as a quantitative measure of the relationship between matrix strain and cell deformation. The results support that these methods can be used to detect strains with high accuracy and can be further extended to an in vivo setting for observing temporal changes in cell and matrix mechanics during degeneration and healing.

Disrupted Tactile Acuity in People With Achilles Tendinopathy: A Preliminary Case-Control Investigation

Study Design Controlled laboratory study, preliminary case-control design. Background The mechanisms that contribute to Achilles tendinopathy remain poorly understood. The disparity between pain experience and peripheral pathology demonstrated in patients with Achilles tendinopathy suggests that changes in central nervous system function may be involved. Objectives To investigate whether lower-limb tactile acuity is impaired in people with nonacute Achilles tendinopathy. Methods Thirteen consecutive participants with nonacute midportion Achilles tendinopathy and 13 healthy controls were enrolled. Two-point discrimination thresholds over the affected Achilles tendon, unaffected tendon, and tendon of healthy controls were evaluated. Independent and dependent t tests were used to compare group means. Results Two-point discrimination distance over the affected limb in participants with Achilles tendinopathy was significantly increased when compared to the unaffected limb (mean difference, 11.7 mm; 95% confidence interval [CI]: 1.9, 21.5; P = .02) and to healthy controls (mean difference, 13.1 mm; 95% CI: 1.6, 24.6; P = .03). There was no significant difference between the healthy controls and the unaffected side in people with Achilles tendinopathy (mean difference, 1.4 mm; 95% CI: -7.9, 5.1; P = .66). Conclusion These data provide the first evidence of reduced 2-point discrimination over the affected tendon in patients with Achilles tendinopathy. Further research is needed to determine the cause for the change in tactile acuity. J Orthop Sports Phys Ther 2016;46(12):1061-1064. Epub 30 Oct 2016. doi:10.2519/jospt.2016.6514.

Tendon functional extracellular matrix

This article is one of a series, summarizing views expressed at the Orthopaedic Research Society New Frontiers in Tendon Research Conference. This particular article reviews the three workshops held under the "Functional Extracellular Matrix" stream. The workshops focused on the roles of the tendon extracellular matrix, such as performing the mechanical functions of tendon, creating the local cell environment, and providing cellular cues. Tendon is a complex network of matrix and cells, and its biological functions are influenced by widely varying extrinsic and intrinsic factors such as age, nutrition, exercise levels, and biomechanics. Consequently, tendon adapts dynamically during development, aging, and injury. The workshop discussions identified research directions associated with understanding cell-matrix interactions to be of prime importance for developing novel strategies to target tendon healing or repair.

Delayed exercise promotes remodeling in sub-rupture fatigue damaged tendons

Tendinopathy is a common musculoskeletal injury whose treatment is limited by ineffective therapeutic interventions. Previously we have shown that tendons ineffectively repair early sub-rupture fatigue damage. In contrast, physiological exercise has been shown to promote remodeling of healthy tendons but its utility as a therapeutic to promote repair of fatigue damaged tendons remains unknown. Therefore, the objective of this study was to assess the utility of exercise initiated 1 and 14 days after onset of fatigue damage to promote structural repair in fatigue damaged tendons. We hypothesized that exercise initiated 14 days after fatigue loading would promote remodeling as indicated by a decrease in area of collagen matrix damage, increased procollagen I and decorin, while decreasing proteins indicative of tendinopathy. Rats engaged in 6-week exercise for 30 min/day or 60 min/day starting 1 or 14 days after fatigue loading. Initiating exercise 1-day after onset of fatigue injury led to exacerbation of matrix damage, particularly at the tendon insertion. Initiating exercise 14 days after onset of fatigue injury led to remodeling of damaged regions in the midsubstance and collagen synthesis at the insertion. Physiological exercise applied after the initial biological response to injury has dampened can potentially promote remodeling of damaged tendons.