Quantitative alterations in intramuscular connective tissue following immobilization: an experimental study in the rat calf muscles

Ultrasonographic measurements of fascicle length overestimate adaptations in serial sarcomere number

Ultrasound-derived measurements of muscle fascicle length (FL) are often used to infer increases (chronic stretch or training) or decreases (muscle disuse or aging) in serial sarcomere number (SSN). Whether FL adaptations measured via ultrasound can truly approximate SSN adaptations has not been investigated. We casted the right hindlimb of 15 male Sprague-Dawley rats in a dorsiflexed position (i.e., stretched the plantar flexors) for 2 weeks, with the left hindlimb serving as a control. Ultrasound images of the soleus, lateral gastrocnemius (LG), and medial gastrocnemius (MG) were obtained with the ankle at 90° and full dorsiflexion for both hindlimbs pre and post-cast. Following post-cast ultrasound measurements, legs were fixed in formalin with the ankle at 90°, then muscles were dissected and fascicles were teased out for measurement of sarcomere lengths via laser diffraction and calculation of SSN. Ultrasound detected an 11% increase in soleus FL, a 12% decrease in LG FL, and an 8-11% increase in MG FL for proximal fascicles and at full dorsiflexion. These adaptations were partly reflected by SSN adaptations, with a 6% greater soleus SSN in the casted leg than the un-casted leg, but no SSN differences for the gastrocnemii. Weak relationships were observed between ultrasonographic measurements of FL and measurements of FL and SSN from dissected fascicles. Our results showed that ultrasound-derived FL measurements can overestimate an increase in SSN by ∼5%. Future studies should be cautious when concluding a large magnitude of sarcomerogenesis from ultrasound-derived FL measurements, and may consider applying a correction factor. NEW FINDINGS: What is the central question of this study? Measurements of muscle fascicle length via ultrasound are often used to infer changes in serial sarcomere number, such as increases following chronic stretch or resistance training, and decreases with ageing: does ultrasound-derived fascicle length accurately depict adaptations in serial sarcomere number? What is the main finding and its importance? Ultrasound detected an ∼11% increase in soleus fascicle length, but measurements on dissected fascicles showed the actual serial sarcomere number increase was only ∼6%; therefore, measurements of ultrasound-derived fascicle length can overestimate serial sarcomere number adaptations by as much as 5%.

Exercise builds the scaffold of life: muscle extracellular matrix biomarker responses to physical activity, inactivity, and aging

Skeletal muscle extracellular matrix (ECM) is critical for muscle force production and the regulation of important physiological processes during growth, regeneration, and remodelling. ECM remodelling is a tightly orchestrated process, sensitive to multi-directional tensile and compressive stresses and damaging stimuli, and its assessment can convey important information on rehabilitation effectiveness, injury, and disease. Despite its profound importance, ECM biomarkers are underused in studies examining the effects of exercise, disuse, or aging on muscle function, growth, and structure. This review examines patterns of short- and long-term changes in the synthesis and concentrations of ECM markers in biofluids and tissues, which may be useful for describing the time course of ECM remodelling following physical activity and disuse. Forces imposed on the ECM during physical activity critically affect cell signalling while disuse causes non-optimal adaptations, including connective tissue proliferation. The goal of this review is to inform researchers, and rehabilitation, medical, and exercise practitioners better about the role of ECM biomarkers in research and clinical environments to accelerate the development of targeted physical activity treatments, improve ECM status assessment, and enhance function in aging, injury, and disease.

Effect of C60 Fullerene on Recovery of Muscle Soleus in Rats after Atrophy Induced by Achillotenotomy

Biomechanical and biochemical changes in the muscle soleus of rats during imitation of hind limbs unuse were studied in the model of the Achilles tendon rupture (Achillotenotomy). Oral administration of water-soluble C₆₀ fullerene at a dose of 1 mg/kg was used as a therapeutic agent throughout the experiment. Changes in the force of contraction and the integrated power of the muscle, the time to reach the maximum force response, the mechanics of fatigue processes development, in particular, the transition from dentate to smooth tetanus, as well as the levels of pro- and antioxidant balance in the blood of rats on days 15, 30 and 45 after injury were described. The obtained results indicate a promising prospect for C₆₀ fullerene use as a powerful antioxidant for reducing and correcting pathological conditions of the muscular system arising from skeletal muscle atrophy.

Consequences of ankle joint immobilisation: insights from a morphometric analysis about fibre typification, intramuscular connective tissue, and muscle spindle in rats

Orthosis immobilisations are routinely used in orthopaedic procedures. This intervention is applicable in bone fractures, ligament injuries, and tendonitis, among other disorders of the musculoskeletal system. We aimed to evaluate the effects of ankle joint functional immobilisation on muscle fibre morphology, connective tissue, muscle spindle and fibre typification triggered by a novel metallic orthosis. We developed a rodent-proof experimental orthosis able to hold the tibiotalar joint in a functional position for short and long terms. The tibialis anterior muscles of free and immobilised legs were collected and stained by histology and histochemistry techniques to investigate general muscle morphology, connective tissue and muscle fibre typification. Morphometric analysis of muscle cross-section area, fibre type cross-section area, fibre type density, percentage of intramuscular connective tissue, and thickness of the muscle spindle capsule were obtained to gain insights into the experimental protocol. We found that short- and long-term immobilisation decreased the cross-section area of the muscles and induced centralisation of myonuclei. The connective tissue of immobilised muscle increased after 2 and 4 weeks mainly by deposition of type III and type I collagen fibres in the perimysium and endomysium, respectively, in addition to muscle spindle capsule thickening. Type IIB muscle fibre was severely affected in our study; the profile assumed odd shapes, and our data suggest interconversion of these fibre types within long-term immobilisation. In conclusion, our protocol has produced structural and histochemical changes in muscle biology. This method might be applied to various rodent models that enable genetic manipulation for the investigation of muscle degeneration/regeneration processes.

The Structure and Role of Intramuscular Connective Tissue in Muscle Function

Extracellular matrix (ECM) structures within skeletal muscle play an important, but under-appreciated, role in muscle development, function and adaptation. Each individual muscle is surrounded by epimysial connective tissue and within the muscle there are two distinct extracellular matrix (ECM) structures, the perimysium and endomysium. Together, these three ECM structures make up the intramuscular connective tissue (IMCT). There are large variations in the amount and composition of IMCT between functionally different muscles. Although IMCT acts as a scaffold for muscle fiber development and growth and acts as a carrier for blood vessels and nerves to the muscle cells, the variability in IMCT between different muscles points to a role in the variations in active and passive mechanical properties of muscles. Some traditional measures of the contribution of endomysial IMCT to passive muscle elasticity relied upon tensile measurements on single fiber preparations. These types of measurements may now be thought to be missing the important point that endomysial IMCT networks within a muscle fascicle coordinate forces and displacements between adjacent muscle cells by shear and that active contractile forces can be transmitted by this route (myofascial force transmission). The amount and geometry of the perimysial ECM network separating muscle fascicles varies more between different muscle than does the amount of endomysium. While there is some evidence for myofascial force transmission between fascicles via the perimysium, the variations in this ECM network appears to be linked to the amount of shear displacements between fascicles that must necessarily occur when the whole muscle contracts and changes shape. Fast growth of muscle by fiber hypertrophy is not always associated with a high turnover of ECM components, but slower rates of growth and muscle wasting may be associated with IMCT remodeling. A hypothesis arising from this observation is that the level of cell signaling via shear between integrin and dystroglycan linkages on the surface of the muscle cells and the overlying endomysium may be the controlling factor for IMCT turnover, although this idea is yet to be tested.

Effects of Twitch Contraction Induced by Magnetic Stimulation on Expression of Skeletal Muscle Fibrosis Related Genes and Limited Range of Motion in Rats

OBJECTIVE

We examined the effects of twitch contraction induced by lumbar spinal root magnetic stimulation on immobilization-induced limited range of motion and skeletal muscle fibrosis in rat soleus muscle.

DESIGN

The groups included male Wistar rats (controls), rats with both bilateral ankle joints immobilized with plaster casts for 4 wks (immobilization [IM]), and rats in which twitch contraction of the soleus muscle was induced by lumbar magnetic stimulation for 4 wks of immobilization (twitch contraction [TC]). Group differences in ankle dorsiflexion range of motion, collagen content as determined by hydroxyproline assay, and the expression of fibrosis-related genes as determined by reverse transcription-polymerase chain reaction (hypoxia inducible factor 1α, α-smooth muscle actin, and types I and III collagen) in the soleus muscle were examined after the 4-wk-long experiment.

RESULTS

Range of motion in the TC group was significantly greater than that in the IM group. The hydroxyproline content and the expressions of fibrosis-related genes decreased significantly in the TC group compared with those in the IM group. No significant differences were seen in the expression of transforming growth factor β mRNA.

CONCLUSIONS

These results suggest that twitch contraction induced by lumbar spinal root magnetic stimulation may reduce immobilization-induced limited range of motion and skeletal muscle fibrosis.

Muscle Atrophy Induced by Mechanical Unloading: Mechanisms and Potential Countermeasures

Prolonged periods of skeletal muscle inactivity or mechanical unloading (bed rest, hindlimb unloading, immobilization, spaceflight and reduced step) can result in a significant loss of musculoskeletal mass, size and strength which ultimately lead to muscle atrophy. With advancement in understanding of the molecular and cellular mechanisms involved in disuse skeletal muscle atrophy, several different signaling pathways have been studied to understand their regulatory role in this process. However, substantial gaps exist in our understanding of the regulatory mechanisms involved, as well as their functional significance. This review aims to update the current state of knowledge and the underlying cellular mechanisms related to skeletal muscle loss during a variety of unloading conditions, both in humans and animals. Recent advancements in understanding of cellular and molecular mechanisms, including IGF1-Akt-mTOR, MuRF1/MAFbx, FOXO, and potential triggers of disuse atrophy, such as calcium overload and ROS overproduction, as well as their role in skeletal muscle protein adaptation to disuse is emphasized. We have also elaborated potential therapeutic countermeasures that have shown promising results in preventing and restoring disuse-induced muscle loss. Finally, identified are the key challenges in this field as well as some future prospectives.

Tendon Length, Calf Muscle Atrophy, and Strength Deficit After Acute Achilles Tendon Rupture: Long-Term Follow-up of Patients in a Previous Study

BACKGROUND

In this prospective study, we used magnetic resonance imaging (MRI) to assess long-term Achilles tendon length, calf muscle volume, and muscle fatty degeneration after surgery for acute Achilles tendon rupture.

METHODS

From 1998 to 2001, 60 patients at our center underwent surgery for acute Achilles tendon rupture followed by early functional postoperative rehabilitation. Fifty-five patients were reexamined after a minimum duration of follow-up of 13 years (mean, 14 years), and 52 of them were included in the present study. Outcome measures included Achilles tendon length, calf muscle volume, and fatty degeneration measured with MRI of both the affected and the uninjured leg. The isokinetic plantar flexion strength of both calves was measured and was correlated with the structural findings.

RESULTS

The Achilles tendon was, on average, 12 mm (95% confidence interval [CI] = 8.6 to 15.6 mm; p < 0.001) longer (6% longer) in the affected leg than in the uninjured leg. The mean volumes of the soleus and medial and lateral gastrocnemius muscles were 63 cm (13%; p < 0.001), 30 cm (13%; p < 0.001), and 16 cm (11%; p < 0.001) lower in the affected leg than in the uninjured leg, whereas the mean volume of the flexor hallucis longus (FHL) was 5 cm (5%; p = 0.002) greater in the affected leg, indicating FHL compensatory hypertrophy. The median plantar flexion strength for the whole range of motion ranged from 12% to 18% less than that on the uninjured side. Finally, the side-to-side difference in Achilles tendon length correlated substantially with the strength deficit (ρ = 0.51, p < 0.001) and with medial gastrocnemius (ρ = 0.46, p = 0.001) and soleus (ρ = 0.42, p = 0.002) muscle atrophy.

CONCLUSIONS

Increased Achilles tendon length is associated with smaller calf muscle volumes and persistent plantar flexion strength deficits after surgical repair of Achilles tendon rupture. Strength deficits and muscle volume deficits are partly compensated for by FHL hypertrophy, but 11% to 13% deficits in soleus and gastrocnemius muscle volumes and 12% to 18% deficits in plantar flexion strength persist even after long-term follow-up.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Cyclic muscle twitch contraction inhibits immobilization-induced muscle contracture and fibrosis in rats

We investigated the effects of cyclic muscle twitch contraction caused by neuromuscular electrical stimulation (NMES) on immobilization-induced muscle contracture and fibrosis in rats. Twenty-nine rats were divided into control, immobilization, and immobilization with muscle contraction groups. The ankle joints of the immobilization and muscle contraction rats were fixed in full plantar flexion with a plaster cast for 4 weeks. In the muscle contraction group, cyclic muscle twitch contraction of the soleus muscle was induced using a commercial device (1 Hz, 4 ± 2 mA, 60 min/day, 5 times/week) with the ankle joint immobilized. The dorsiflexion range of ankle joint motion in the muscle contraction group was significantly greater than that in the immobilization group. The expressions of fibrosis-related genes (i.e., hypoxia inducible factor-1α, transforming growth factor-β1, α-smooth muscle actin, and types I and III collagen) were significantly decreased in the muscle contraction group compared to the immobilization group. The fluorescence intensities of type I and type III collagen in the perimysium and endomysium in the muscle contraction group were significantly decreased compared to the immobilization group. These results suggest that cyclic muscle twitch contraction induced by NMES might alleviate skeletal muscle fibrosis, reducing immobilization-induced muscle contracture.

Soleus Atrophy Is Common After the Nonsurgical Treatment of Acute Achilles Tendon Ruptures: A Randomized Clinical Trial Comparing Surgical and Nonsurgical Functional Treatments

BACKGROUND

It remains controversial whether nonsurgical or surgical treatment provides better calf muscle strength recovery after an acute Achilles tendon rupture (ATR). Recent evidence has suggested that surgery might surpass nonsurgical treatment in restoring strength after an ATR.

PURPOSE

To assess whether magnetic resonance imaging (MRI) findings could explain calf muscle strength deficits and the difference between nonsurgical and surgical treatments in restoring calf muscle strength.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

From 2009 to 2013, 60 patients with acute ATRs were randomized to surgery or nonsurgical treatment with an identical rehabilitation protocol. The primary outcome measure was the volume of calf muscles assessed using MRI at 3 and 18 months. The secondary outcome measures included fatty degeneration of the calf muscles and length of the affected Achilles tendon. Additionally, isokinetic plantarflexion strength was measured in both legs.

RESULTS

At 3 months, the study groups showed no differences in muscle volumes or fatty degeneration. However, at 18 months, the mean differences between affected and healthy soleus muscle volumes were 83.2 cm³ (17.7%) after surgery and 115.5 cm³ (24.8%) after nonsurgical treatment (difference between means, 33.1 cm³; 95% CI, 1.3-65.0; P = .042). The study groups were not substantially different in the volumes or fatty degeneration of other muscles. From 3 to 18 months, compensatory hypertrophy was detected in the flexor hallucis longus (FHL) and deep flexors in both groups. In the nonsurgical treatment group, the mean difference between affected and healthy FHL muscle volumes was -9.3 cm³ (12%) and in the surgical treatment group was -8.4 cm³ (10%) ( P ≤ .001). At 18 months, Achilles tendons were, on average, 19 mm longer in patients treated nonsurgically compared with patients treated surgically ( P < .001). At 18 months, surgically treated patients demonstrated 10% to 18% greater strength results ( P = .037). Calf muscle isokinetic strength deficits for the entire range of ankle motion correlated with soleus atrophy (ρ = 0.449-0.611; P < .001).

CONCLUSION

Treating ATRs nonsurgically with a functional rehabilitation protocol resulted in greater soleus muscle atrophy compared with surgical treatment. The mean Achilles tendon length was 19 mm longer after nonsurgical treatment than after the surgical treatment of ATRs. These structural changes partly explained the 10% to 18% greater calf muscle strength observed in patients treated with surgery compared with those treated nonsurgically. Registration: NCT02012803 ( ClinicalTrials.gov identifier).

A homogenization model of the Voigt type for skeletal muscle

A three-dimensional constitutive model for skeletal muscle incorporating microstructural characteristics is developed and numerically implemented in a general purpose finite element program. The proposed model takes into account explicitly the volume fractions of muscle fibers and connective tissue by using the Voigt homogenization approach to bridge the different length scales of the muscle structure. The model is used to estimate the active and passive homogenized muscle response. Next, the model is validated by experimental data and periodic three-dimensional unit cell calculations comprising various fiber volume fractions and mechanical properties of the constituents. The model is found to be in very good agreement with both the experimental data and the finite element results for all the examined cases. The influence of fiber volume fraction and material properties of constituents on effective muscle response under several loading conditions is examined.

Cyclooxygenase-2 inhibitor celecoxib attenuates joint contracture following immobilization in rat knees

Background

The aim of this study is to clarify the following two points: First, whether a cyclooxygenase-2 mediated pathway is involved in the formation of immobilization-induced joint contracture and, second, the effectiveness of oral administration of non-steroidal anti-inflammatory drug celecoxib (CBX) for the prevention of myogenic and arthrogenic contracture following immobilization in a rat model.

Methods

Thirty male rats were randomly divided into three groups: immobilization (Im), Im + CBX, and control (n = 10 each). External fixation immobilized the right knee joint of Im and Im + CBX groups in flexion for 3 weeks. 50 mg/kg of CBX was administrated daily to the Im + CBX group during this period. The passive range of motion (ROM) of knee joints was measured before and after transection of knee flexor muscles and myogenic and arthrogenic ROM restrictions were calculated. The semitendinosus muscles and knee joints were investigated histologically to elucidate factors responsible for contracture.

Results

Myogenic ROM restrictions were exhibited both in Im and Im + CBX groups (44 ± 5 and 36 ± 8 °, respectively), but restrictions significantly decreased in the Im + CBX group compared to the Im group. Significant reductions of the muscle length ratios (Rt/Lt) and sarcomere number ratios (Rt/Lt) in knee flexor semitendinosus muscle, which are responsible for myogenic contracture, were also seen both in Im group (92 ± 5 and 92 ± 4 %, respectively) and Im + CBX group (97 ± 3 and 97 ± 3 %, respectively), but were inhibited by CBX administration (P < 0.05). Im and Im + CBX groups exhibited arthrogenic ROM restrictions with no significant differences (82 ± 3 and 83 ± 5 °, respectively). Posterior synovial length shortening and pathological changes (hemorrhage in joint cavities and capsule edema) in the knee joints were comparable between Im and Im + CBX groups.

Conclusions

Oral administration of celecoxib partially reduced myogenic ROM restriction concomitantly with knee flexor muscle shortening following immobilization. These results imply that inflammation and nociception are involved in myogenic contracture formation independently of joint immobilization, and that CBX is effective in preventing joint contracture following immobilization in rats.

In Vivo Rodent Models of Skeletal Muscle Adaptation to Decreased Use

Skeletal muscle possesses plasticity and adaptability to external and internal physiological changes. Due to these characteristics, skeletal muscle shows dramatic changes depending on its response to stimuli such as physical activity, nutritional changes, disease status, and environmental changes. Modulation of the rate of protein synthesis/degradation plays an important role in atrophic responses. The purpose of this review is to describe different features of skeletal muscle adaptation with various models of deceased use. In this review, four models were addressed: immobilization, spinal cord transection, hindlimb unloading, and aging. Immobilization is a form of decreased use in which skeletal muscle shows electrical activity, tension development, and motion. These results differ by muscle group. Spinal cord transection was selected to simulate spinal cord injury. Similar to the immobilization model, dramatic atrophy occurs in addition to fiber type conversion in this model. Despite the fact that electromyography shows unremarkable changes in muscle after hindlimb unloading, decreased muscle mass and contractile force are observed. Lastly, aging significantly decreases the numbers of muscle fibers and motor units. Skeletal muscle responses to decreased use include decreased strength, decreased fiber numbers, and fiber type transformation. These four models demonstrated different changes in the skeletal muscle. This review elucidates the different skeletal muscle adaptations in these four decreased use animal models and encourages further studies.

DJ-1 protects against undernutrition-induced atrophy through inhibition of the MAPK-ubiquitin ligase pathway in myoblasts

AIMS

The purpose of this study is to explore whether antioxidant DJ-1 protein affects the atrophy of skeletal muscle cell induced by undernutrition.

MAIN METHODS

To determine cell atrophic responses, L6 cell line and skeletal primary cells from mouse hind limbs were cultivated under condition of FBS-free and low glucose. Changes of protein expression were analyzed using Western blot. Overexpression and knockdown of DJ-1 was performed in cells to assess its influence on cell atrophic responses.

KEY FINDINGS

Undernutrition decreased cell size and increased the abundance of oxidized form and total form of DJ-1 protein in L6 myoblasts. The undernourished cells revealed an elevation in the expression of muscle-specific RING finger-1 (MuRF-1) and atrogin-1, and in the phosphorylations of p38 mitogen-activated protein kinase (MAPK) and stress-activated protein kinase/c-Jun N-terminal kinase compared with control groups. Moreover, DJ-1-knockout mice showed a decrease in cell size and an enhancement in the expression of MuRF-1 and atrogin-1, as well as in the phosphorylation of MAPKs in gastrocnemius muscles; these changes were also observed in L6 cells transfected with siRNA of DJ-1. On the other hand, L6 cells overexpressing full-length DJ-1 did not exhibit the alterations in cell size and ubiquitin ligases seen after undernourished states of control cells. Myotubes differentiated from L6 cells also showed elevated expression of MuRF-1 and atrogin-1 in response to undernutrition.

SIGNIFICANCE

These results suggest that DJ-1 protein may contribute to undernutrition-induced atrophy via MAPKs/ubiquitin ligase pathway in skeletal muscle cells.

Collagen Type III and VI Turnover in Response to Long-Term Immobilization

BACKGROUND

Muscle mass and function are perturbed by immobilization and remobilization. When muscle mass changes, the quality and quantity of the extracellular matrix protein, particularly the collagens, change with it. In this study, we investigated the temporal profile of three peptide biomarkers derived from turnover of collagen type III and type VI in a long-term immobilization and remobilization study. We also compared individual biomarker levels with Lean body Mass (LBM) and changes therein, hypothesizing that these biomarkers would be biomarkers of the remodeling processes associated with immobilization and/or remobilization.

METHODS

In the Berlin bed rest study, 20 young men were recruited and randomly assigned to 8-week's strict bed rest with or without resistive vibration exercise countermeasure. We measured three neo-epitope ELISA kits in the serum samples of this study: Pro-C3, measured the synthesis of collagen type III; Pro-C6, measured the synthesis of collagen type VI; and C6M measured the degradation of collagen type VI induced by MMP-2 and MMP-9 cleavage.

RESULTS

Pro-C3 and Pro-C6 biomarkers are up-regulated with both immobilization and remobilization, whereas C6M is hardly affected at all. We found that Pro-C3 and C6M levels are related to LBM at baseline and that high levels of Pro-C6 are associated with smaller changes in muscle mass during both immobilization and remobilization.

CONCLUSION

The Pro-C3 and-C6 biomarkers change likely reflect remodeling changes in response to unloading or reloading, whereas C6M does not appear to respond to unloading. Pro-C3 and C6M levels correlate with LBM at baseline, while Pro-C6 is related to the anabolic and catabolic responses to unloading and reloading.

Quantitative and temporal differential recovery of articular and muscular limitations of knee joint contractures; results in a rat model

Joint contractures alter the mechanical properties of articular and muscular structures. Reversibility of a contracture depends on the restoration of the elasticity of both structures. We determined the differential contribution of articular and muscular structures to knee flexion contractures during spontaneous recovery. Rats (250, divided into 24 groups) had one knee joint surgically fixed in flexion for six different durations, from 1 to 32 wk, creating joint contractures of various severities. After the fixation was removed, the animals were left to spontaneously recover for 1 to 48 wk. After the recovery periods, animals were killed and the knee extension was measured before and after division of the transarticular posterior muscles using a motorized arthrometer. No articular limitation had developed in contracture of recent onset (≤2 wk of fixation, P > 0.05); muscular limitations were responsible for the majority of the contracture (34 ± 8° and 38 ± 6°, respectively; both P < 0.05). Recovery for 1 and 8 wk reversed the muscular limitation of contractures of recent onset (1 and 2 wk of fixation, respectively). Long-lasting contractures (≥4 wk of fixation) presented articular limitations, irreversible in all 12 durations of recovery compared with controls (all 12 P < 0.05). Knee flexion contractures of recent onset were primarily due to muscular structures, and they were reversible during spontaneous recovery. Long-lasting contractures were primarily due to articular structures and were irreversible. Comprehensive temporal and quantitative data on the differential reversibility of mechanically significant alterations in articular and muscular structures represent novel evidence on which to base clinical practice.

Regulation of connective tissue remodeling in the early phase of denervation in a rat skeletal muscle

Denervation alters the metabolism of the extracellular matrix (ECM) in skeletal muscle; however, the underlying mechanisms of ECM remodeling are not fully understood. The aim of this study was to elucidate the dynamic features of the ECM regulatory process in the early phase of denervated skeletal muscle in male Wistar rats. We investigated the expression of collagens (total, type I, and type III), transforming growth factor beta 1 (TGF-β1), and matrix metalloproteases (MMPs) together with their endogenous inhibitors (TIMPs), at the mRNA and/or protein level in the soleus muscles of control animals and at days 3, 7, and 14 post-denervation. Expression of mRNA encoding collagens was decreased at days 3 and 7, and had recovered by day 14, in parallel with total collagen protein content. Content of TGF-β1 protein was elevated sequentially, up to a maximum of 158% at day 14 post-denervation (P < 0.05), as was TIMP-2 mRNA expression (272% at day 14), whereas MMP-1, MMP-2, and TIMP-1 mRNA expression was not affected at any stage. The initial reduction of collagen mRNA may be responsible for hypoactivity caused by the disappearance of contractile function. Recovery of collagen mRNA/protein at day 14 may be due mainly to the suppressive effects of TGF-β1 on collagen degradation via TIMP-2 upregulation.

Recent advances following anterior cruciate ligament reconstruction: rehabilitation perspectives : Critical reviews in rehabilitation medicine

Injuries to the anterior cruciate ligament are common. Surgical reconstruction is more prevalent than ever. This review article discusses treatment of the patient following surgical reconstruction of the anterior cruciate ligament. Various phases of rehabilitation are discussed with emphasis on early return of passive motion, early weight bearing, bracing, kinetic chain exercises, neuromuscular electrical stimulation and accelerated rehabilitation. Although evidence exists for the treatment of the surgically reconstructed cruciate ligament, more is needed to better define specific timeframes for advancement. Evidence exists that many of these young individuals are not fully returning to unlimited high level activities. This review article presents some of the latest evidence regarding anterior cruciate ligament rehabilitation in an attempt to help the busy clinician understand and relate basic and clinical research to rehabilitation of a patient following reconstruction.

Accelerated versus nonaccelerated rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind investigation evaluating knee joint laxity using roentgen stereophotogrammetric analysis

BACKGROUND

The relationship between the biomechanical dose of rehabilitation exercises administered after anterior cruciate ligament (ACL) reconstruction and the healing response of the graft and knee is not well understood.

HYPOTHESIS

After ACL reconstruction, rehabilitation administered with either accelerated or nonaccelerated programs produces the same change in the knees' 6 degrees of freedom, or envelope, laxity values.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients who underwent ACL reconstruction with a bone-patellar tendon-bone autograft were randomized to rehabilitation with either accelerated (19 week) or nonaccelerated (32 week) programs. At the time of surgery, and then 3, 6, 12, and 24 months later, the 6 degrees of freedom knee laxity values were measured using roentgen stereophotogrammetric analysis and clinical, functional, and patient-oriented outcome measures.

RESULTS

Eighty-five percent of those enrolled were followed through 2 years. Laxity of the reconstructed knee was restored to within the limits of the contralateral, normal side at the time of surgery (baseline) in all participants. Patients in both programs underwent a similar increase in the envelope of knee laxity over the 2-year follow-up interval (anterior-posterior translation 3.2 vs 4.5 mm, and coupled internal-external rotations 2.6° vs 1.9° for participants in the accelerated and nonaccelerated programs, respectively). Those who underwent accelerated rehabilitation experienced a significant improvement in thigh muscle strength at the 3-month follow-up (P < .05) compared with those who participated in nonaccelerated rehabilitation, but no differences between the programs were seen after this time interval. At the 2-year follow-up, the groups were similar in terms of clinical assessment, patient satisfaction, function, proprioception, and isokinetic thigh muscle strength.

CONCLUSION

Rehabilitation with the accelerated and nonaccelerated programs administered in this study produced the same increase in the envelope of knee laxity. A majority of the increase in the envelope of knee laxity occurred during healing when exercises were advanced and activity level increased. Patients in both programs had the same clinical assessment, functional performance, proprioception, and thigh muscle strength, which returned to normal levels after healing was complete. For participants in both treatment programs, the Knee Injury and Osteoarthritis Outcome Score (KOOS) assessment of quality of life did not return to preinjury levels.

Effect of Immobilization on Insoluble Collagen Concentration and Type I and Type III Collagen Isoforms of Rat Soleus Muscle

Immobilization is often associated with decreased muscle elasticity. This condition is known as muscle contracture; however, the mechanism remains unclear. The purpose of this study was to clarify the mechanism governing muscle contracture in rat soleus muscle by identifying changes in ankle joint mobility, insoluble collagen concentration and type I and type III collagen isoforms following 1- and 3-week immobilizations. Following a 1-week immobilization, range of motion (ROM) of dorsiflexion declined to 90% of the control value; additionally, ROM dropped to 67.5% of the control value after a 3-week immobilization. This finding suggested that ankle joint mobility decreases in conjunction with extended periods of immobilization. Insoluble collagen concentration in soleus muscles, which was unchanged after 1 week of immobilization, increased 3 weeks after immobilization. These results may be indicative of collagen fibers with strong intermolecular cross-links contained in the muscle was made increased relatively by 3 weeks of immobilization. Therefore, the change in intermolecular cross-links may be significant in terms of progress of muscle contracture with longer periods of immobilization. On the other hand, the ratio of type III to type I collagen isoforms in muscular tissue increased following a 1-week immobilization; moreover, this ratio remained constant after 3 weeks of immobilization. These data suggested that muscle immobilization may induce type III collagen isoform expression. The increase in the ratio of type III to type I collagen isoforms do not change in parallel with the increase in the limitation in ROM; however, this phenomenon probably is not closely related to the progress of muscle contracture. The change of collagen isoform in immobilized muscle may be involved in the mechanism governing the progression of muscle fibrosis.

Treatment of anterior cruciate ligament injuries, part 2

Anterior cruciate ligament tears, common among athletes, are functionally disabling; they predispose the knee to subsequent injuries and the early onset of osteoarthritis. A total of 3810 studies published between January 1994 and the present were identified and reviewed to determine the current state of knowledge regarding the treatment of anterior cruciate ligament injuries. Part 1 of this article focused on studies pertaining to the biomechanical behavior of the anterior cruciate ligament, the prevalence of and risk factors for injuries related to it, the natural history of the ligament-deficient knee, injuries associated with anterior cruciate ligament disruption, indications for the treatment of anterior cruciate ligament injuries, as well as nonoperative and operative treatments. Part 2 includes technical aspects of anterior cruciate ligament surgery, bone tunnel widening, graft healing, rehabilitation after anterior cruciate ligament reconstruction, and the effects of sex, age, and activity level on the outcome of such reconstructive surgery.

Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals

BACKGROUND

There are adverse effects associated with immobilization of the knee after anterior cruciate ligament reconstruction, yet very little is known about how much activity will promote adequate rehabilitation without permanently elongating the graft, producing graft failure, or creating damage to articular cartilage.

HYPOTHESIS

Rehabilitation with either an accelerated or nonaccelerated program produces no difference in anterior-posterior knee laxity, clinical assessment, patient satisfaction, functional performance, and the synovial fluid biomarkers of articular cartilage metabolism.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Twenty-five patients who tore their anterior cruciate ligament were enrolled and underwent anterior cruciate ligament reconstruction. Patients were randomized to accelerated rehabilitation or nonaccelerated rehabilitation. At the time of surgery and 3, 6, 12, and 24 months later, measurements of anterior-posterior knee laxity, clinical assessment, patient satisfaction, functional performance, and cartilage metabolism were completed.

RESULTS

At the 2-year follow-up, there was no difference in the increase of anterior knee laxity relative to the baseline values that were obtained immediately after surgery between the 2 groups (2.2-mm vs 1.8-mm increase relative to the normal knee). The groups were similar in terms of clinical assessment, patient satisfaction, activity level, function, and response of the bio-markers. After 1 year of healing, synthesis of collagen and turnover of aggrecan remained elevated in both groups.

CONCLUSION

Anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft followed by either accelerated or nonaccelerated rehabilitation produces the same increase of anterior knee laxity. Both programs had the same effect in terms of clinical assessment, patient satisfaction, functional performance, and the biomarkers of articular cartilage metabolism. There is concern that the cartilage biomarkers remained elevated for an extended period.

Recovery from immobilisation: responses of fast-twitch muscle fibres to spontaneous and intensive exercise in rat calf muscles

Four weeks of immobilisation with two types of re-mobilisation programmes (intensive concentric treadmill exercising during 6 days, and free exercising, and immobilisation without any re-mobilisation period were studied to clarify possible exercise-induced calf muscle damage especially in fast-twitch fibres used in running compared to non-immobilised rats housing freely in their cages. As markers of muscle injury, conventional histology, beta-glucuronidase (beta-GU) activity and fetal myosin heavy chain expression (MHC-d) were assessed on Days 0, 1, 3, 6 and 14 after the cast removal. Only minor focal hypercontraction, ruptures and necrosis of myofibrils, and weak inflammatory cell reactions were found in all samples examined, except in the controls. No MHC-d positive cells were found indicating absence of active regeneration after immobilisation or re-mobilisation. Minor increase in beta-GU activity was observed in all three muscles studied, but statistically significant increase was observed only in the samples of the free exercising group on Day 14 after the cast removal. To conclude, intensive concentric treadmill exercise for 6 days did not cause significantly more muscle damage than did free exercising re-mobilisation.

Organization and distribution of intramuscular connective tissue in normal and immobilized skeletal muscles. An immunohistochemical, polarization and scanning electron microscopic study

Collagen fiber network is a major contributor to the coherence and tensile strength of normal skeletal muscle. Despite the well-recognized importance of the intramuscular connective tissue to the normal integrity and function of the skeletal muscle, the specific architecture including the location and three-dimensional orientation of the intramuscular connective tissue within the muscle tissue is poorly described. The structure of the intramuscular connective tissue was studied by immunohistochemistry, polarization microscopy (the crimp length and angle of the collagen fibers) and scanning electron microscope (SEM) in rat skeletal muscles (gastrocnemius, soleus and tibialis anterior) in normal situation and after 3 weeks of disuse (immobilization). Three separate networks of collagen fibers were distinguished by SEM in the normal endomysium; fibers running longitudinally on the surface of the muscle fibers (the main collagen orientation), fibers running perpendicularly to the long axis of the muscle fibers and having contacts with adjacent muscle fibers, and fibers attached to the intramuscular nerves and arteries. Similarly, the SEM analysis also disclosed three distinct collagen fiber networks running in different directions in the perimysium, but, contrary to the endomysium, the main fiber orientation could not be established. Immobilization resulted in a marked increase in the endo- and perimysial connective tissue, the majority of the increased endomysial collagen being deposited directly on the sarcolemma of the muscle cells. Immobilization also resulted in substantial increase in the number of perpendicularly oriented collagen fibers with contacts to two adjacent muscle fibers in the endomysium. Further, immobilization clearly disturbed the normal structure of the endomysium making it impossible to distinguish the various networks of fibers from each other. In the perimysium, immobilization-induced changes were similar, the number of longitudinally oriented collagen fibers was increased, the connective tissue was very dense, the number of irregularly oriented collagen fibers was markedly increased, and consequently, the different networks of collagen fibers could not be distinguished from each other. Of the three studied intact muscles, the crimp angle of the collagen fibers was lowest in the soleus and highest in the gastrocnemius muscle, and the crimp angle decreased over 10% in all muscles after the immobilization-period. Altogether, the above described quantitative and qualitative changes in the intramuscular connective tissue are likely to contribute to the deteriorated function and biomechanical properties of the immobilized skeletal muscle.

Kinematic analysis of the hind limb during swimming and walking in healthy dogs and dogs with surgically corrected cranial cruciate ligament rupture

OBJECTIVE

To determine hip, stifle, and tarsal joint ranges of motion (ROM) and angular velocities during swimming and walking in healthy dogs and dogs with surgically corrected cranial cruciate ligament (CCL) rupture.

DESIGN

Prospective clinical study.

ANIMALS

13 healthy dogs and 7 dogs with CCL rupture.

PROCEDURE

Dogs with CCL rupture were enrolled in a postoperative aquatic rehabilitation program and evaluated 21 to 35 days after surgery. Dogs were filmed while swimming in a pool and while walking at a fast (1.3 m/s) or slow (0.9 m/s) pace on a treadmill. Maximal angles of extension and flexion, ROM, and angular velocities were calculated.

RESULTS

In healthy dogs, swimming resulted in a significantly greater ROM in the hip joint than did walking, but in dogs with CCL rupture, ROM of the hip joint did not vary with swimming versus walking. For dogs in both groups, swimming resulted in significantly greater ROM of the stifle and tarsal joints than did walking, primarily because of greater joint flexion. Stifle joint ROM was significantly lower in dogs with CCL rupture than in healthy dogs, regardless of whether dogs were swimming or walking.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that following surgical management of a ruptured CCL in dogs, swimming resulted in greater ROM of the stifle and tarsal joints than did walking. This suggests that if ROM is a factor in the rate or extent of return to function in these dogs, then aquatic rehabilitation would likely result in a better overall outcome than walking alone.

The science of anterior cruciate ligament rehabilitation

This review of the literature assessed what is known about the biomechanics of the normal anterior cruciate ligament during rehabilitation exercises, the biomechanical behavior of the anterior cruciate ligament graft during healing, and clinical studies of rehabilitation after anterior cruciate ligament replacement. After anterior cruciate replacement, immobilization of the knee, or restricted motion without muscle contraction, leads to undesired outcomes for the ligamentous, articular, and muscular structures that surround the joint. It is clear that rehabilitation that incorporates early joint motion is beneficial for reducing pain, minimizing capsular contractions, decreasing scar formation that can limit joint motion, and is beneficial for articular cartilage. There is evidence derived from randomized controlled trials that immediately after anterior cruciate ligament reconstruction, weightbearing is possible without producing an increase of anterior knee laxity and is beneficial because it lowers the incidence of patellofemoral pain. Rehabilitation with a closed kinetic chain program results in anteroposterior knee laxity values that are closer to normal, and earlier return to normal daily activities, compared with rehabilitation with an open kinetic chain program. This review revealed that more randomized, controlled trials of rehabilitation are needed. These should include the clinicians' and patients' perspective of the outcome, and biomarkers of articular cartilage metabolism.

Prolonged unloading of rat soleus muscle causes distinct adaptations of the gene profile

Using commercially available microarray technology, we investigated a series of transcriptional adaptations caused by atrophy of rat m. soleus due to 35 days of hindlimb suspension. We detected 395 out of 1,200 tested transcripts, which reflected 1%-5% of totally expressed genes. From various cellular functional pathways, we detected multiple genes that spanned a 200-fold range of gene expression levels. Statistical analysis combining L1 regression with the sign test based on the conservative Bonferroni correction identified 105 genes that underwent transcriptional adaptations with atrophy. Generally, expressional changes were discrete (<50%) and pointed in the same direction for genes belonging to the same cellular functional units. In particular, a distinct expressional adaptation of genes involved in fiber transformation; that is, metabolism, protein turnover, and cell regulation were noted and matched to corresponding transcriptional changes in nutrient trafficking. Expressional changes of extracellular proteases, and of genes involved in nerve-muscle interaction and excitation-contraction coupling identify previously not recognized adaptations that occur in atrophic m. soleus. Considerations related to technical and statistical aspects of the array approach for profiling the skeletal muscle genome and the impact of observed novel adaptations of the m. soleus transcriptome are put into perspective of the physiological adaptations occurring with muscular atrophy.

Effects of postoperative rehabilitation on limb function after cranial cruciate ligament repair in dogs

OBJECTIVE

To determine the effects of early postoperative rehabilitation on limb function in dogs after surgery for ruptured cranial cruciate ligament (RCCL).

DESIGN

Prospective clinical study.

ANIMALS

51 client-owned dogs.

PROCEDURE

Dogs weighing between 20 and 40 kg (44 to 88 lb) that had RCCL and medial meniscal injury were studied. After removal of the RCCL and complete medial meniscectomy, the stifle joint was stabilized by use of a lateral retinacular stabilization technique. Twenty-five dogs were included in a postoperative rehabilitation group, and 26 dogs were included in an exercise-restricted group. Limb function (peak vertical force [PVF] and vertical impulse [VI]) was determined before surgery and 6 months after surgery, using force platform gait analysis.

RESULTS

Prior to surgery, mean PVF and VI in affected limbs were similar between groups. Six months after surgery, PVF and VI were significantly increased in dogs of both groups. However, PVF and VI in dogs in the rehabilitation group were significantly greater than those of dogs in the exercise-restricted group. At this time, differences in limb function (as measured by PVF and VI) between the repaired and normal limbs were not evident in dogs in the rehabilitation group. Conversely, limb function in the repaired limb of dogs in the exercise-restricted group was still significantly less than that of the normal limb.

CONCLUSION AND CLINICAL RELEVANCE

Dogs that have surgery for RCCL and a torn medial meniscus benefit from postoperative rehabilitation; rehabilitation should be considered part of the postoperative management of these patients.

Conservative treatment of acute lateral ankle sprains

Lateral ankle sprains are among the most common sports injuries. Although ankle sprains are treated conservatively at the present time, for years the treatment was based on acute repair of the ruptured ligaments. Several differing opinions currently exist as to the treatment of lateral ankle sprains. A review of the literature and explanation of the benefits and risks of each treatment protocol is undertaken.

Resistance vessel remodeling and reparative angiogenesis in the microcirculatory bed of long-term denervated skeletal muscles

In denervated skeletal muscles, atrophy of muscle fibers and interstitial fibrosis are associated with alterations within the vascular bed. Our study has placed particular emphasis on changes occurring in resistance vessels and the microcirculatory bed of rat hindlimb skeletal muscles that had been denervated for 25 months. We found that the tunica media of the majority of long-term denervated resistance vessels undergoes deterioration. In small intramuscular arteries and arterioles, atrophic vascular smooth muscle cells (vSMCs) enclosed in a thick basal lamina are separated by expanded extracellular space. The remodeling and sclerotic changes in the arterial wall occasionally result in deformation of the lumen. It was also found that the microcirculatory bed undergoes significant alterations. In 25-month denervated extensor digitorum longus muscle, the capillary-to-fiber ratio is only 0.13 +/- 0.01 and the mean number of capillaries per fascicle decreases almost ninefold compared to contralateral control muscle. Ultrastructural findings demonstrate that 24.67 +/- 0.48% of capillaries examined in the chronically denervated fascicles show structural features typical for capillary regeneration. In addition, long cytoplasmic extensions of pericytes might develop a layer completely encircling the capillary endothelium. In pre- and postcapillary segments of the microcirculatory bed, some perivascular cells possess a phenotype that is intermediate between that of pericytes and atrophic vSMCs. RT-PCR and/or Western blot analyses showed that molecules participating in angiogenesis are detected in 25-month denervated skeletal muscle. We hypothesize that despite the fact that the microcirculatory bed of chronically denervated muscle undergoes significant reduction it still sustains the capacity for reparative capillary growth.

Regulation of synthesis of fibrillar collagens in rat skeletal muscle during immobilization in shortened and lengthened positions

Immobilization has been shown to cause muscle atrophy and decreased total collagen synthesis in skeletal muscle. These changes can be counteracted by stretch. The purpose of this study was to find out the early effects of immobilization in shortened and lengthened positions on expression of type I and III collagen at pre- and post-translational level. The mRNA levels of type I and III collagen, prolyl 4-hydroxylase activity, total collagen concentration and the proportions of type I and III collagens were analysed in soleus (SOL), gastrocnemius (GM), extensor digitorum longus and tibialis anterior (TA) muscles during immobilization in shortened and lengthened positions for 1, 3 and 7 days. The mRNA levels for type I and III collagens decreased during 3-7 days in all muscles, except TA. In shortened GM and SOL, the mRNA level of type I collagen was lower than in the corresponding lengthened muscles. Prolyl 4-hydroxylase activity decreased in all muscles during 3-7 days. The activity in shortened GM was 30-37% lower than in the lengthened one during 3-7 days. Total collagen concentration and proportions of type I and III collagen showed no change during the 7-day immobilization period. The present study suggests that immobilization results in rapid down-regulation of total muscular collagen synthesis and that the timing and degree is roughly similar in type I and III collagens. Stretch seems to partially counteract these effects. Immobilization effect and the partially preventive effect of stretch on down-regulation of gene expression of prolyl 4-hydroxylase and fibrillar collagens during immobilization seems to be greater in weight-bearing SOL and GM than ankle joint dorsiflexors.

mRNA levels for alpha-subunit of prolyl 4-hydroxylase and fibrillar collagens in immobilized rat skeletal muscle

There is evidence that immobilization causes a decrease in total collagen synthesis in skeletal muscle within a few days. In this study, early immobilization effects on the expression of prolyl 4-hydroxylase (PH) and the main fibrillar collagens at mRNA and protein levels were investigated in rat skeletal muscle. The right hindlimb was immobilized in full plantar flexion for 1, 3, and 7 days. Steady-state mRNAs for alpha- and beta-subunits of PH and type I and III procollagen, PH activity, and collagen content were measured in gastrocnemius and plantaris muscles. Type I and III procollagen mRNAs were also measured in soleus and tibialis anterior muscles. The mRNA level for the PH alpha-subunit decreased by 49 and 55% (P < 0.01) in gastrocnemius muscle and by 41 and 39% (P < 0.05) in plantaris muscle after immobilization for 1 and 3 days, respectively. PH activity was decreased (P < 0.05-0.01) in both muscles at days 3 and 7. The mRNA levels for type I and III procollagen were decreased by 26-56% (P < 0.05-0.001) in soleus, tibialis anterior, and plantaris muscles at day 3. The present results thus suggest that pretranslational downregulation plays a key role in fibrillar collagen synthesis in the early phase of immobilization-induced muscle atrophy.

Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment

Acute lateral ankle ligament sprains are common in young athletes (15 to 35 years of age). Diagnostic and treatment protocols vary. Therapies range from cast immobilisation or acute surgical repair to functional rehabilitation. The lateral ligament complex includes 3 capsular ligaments: the anterior tibiofibular (ATFL), calcaneofibular (CFL) and posterior talofibular (PTFL) ligaments. Injuries typically occur during plantar flexion and inversion; the ATFL is most commonly torn. The CFL and the PTFL can also be injured and, after severe inversion, subtalar joint ligaments are also affected. Commonly, an athlete with a lateral ankle ligament sprain reports having 'rolled over' the outside of their ankle. The entire ankle and foot must be examined to ensure there are no other injuries. Clinical stability tests for ligamentous disruption include the anterior drawer test of ATFL function and inversion tilt test of both ATFL and CFL function. Radiographs may rule out treatable fractures in severe injuries or when pain or tenderness are not associated with lateral ligaments. Stress radiographs do not affect treatment. Ankle sprains are classified from grades I to III (mild, moderate or severe). Grade I and II injuries recover quickly with nonoperative management. A non-operative 'functional treatment' programme includes immediate use of RICE (rest, ice, compression, elevation), a short period of immobilisation and protection with a tape or bandage, and early range of motion, weight-bearing and neuromuscular training exercises. Proprioceptive training on a tilt board after 3 to 4 weeks helps improve balance and neuromuscular control of the ankle. Treatment for grade III injuries is more controversial. A comprehensive literature evaluation and meta-analysis showed that early functional treatment provided the fastest recovery of ankle mobility and earliest return to work and physical activity without affecting late mechanical stability. Functional treatment was complication-free, whereas surgery had serious, though infrequent, complications. Functional treatment produced no more sequelae than casting with or without surgical repair. Secondary surgical repair, even years after an injury, has results comparable to those of primary repair, so even competitive athletes can receive initial conservative treatment. Sequelae of lateral ligament injuries are common. After conservative or surgical treatment, 10 to 30% of patients have chronic symptoms, including persistent synovitis or tendinitis, ankle stiffness, swelling, pain, muscle weakness and 'giving-way'. Well-designed physical therapy programmes usually reduce instability. For individuals with chronic instability refractory to conservative measures, surgery may be needed. Subtalar instability should be carefully evaluated when considering surgery.

Hamstring Muscle Strength Prior to and Following ACL Reconstruction Surgery Using a Patellar Tendon Autograft

Due to the likelihood of hamstring dysfunction associated with anterior cruciate ligament (ACL) injury, it is clinically significant to determine if a hamstring weakness exists preoperatively. The purpose of this study was to determine if a hamstring muscle deficit existed at the time of surgery and to determine the time necessary to achieve hamstring strength equal to preoperative measures of the uninvolved extremity during postoperative rehabilitation. Twelve patients who underwent ACL reconstruction using a patellar tendon autograft participated. Each subject underwent a preoperative isometric knee strength evaluation at 60° of knee flexion. Each subject underwent postoperative rehabilitation including hamstring muscle strengthening. Repeat isometric testing was performed on each subject at 21 and 42 days postoperative. There was no statistical difference in hamstring muscle strength, as measured by isometric peak torque, either preoperatively or postoperatively. Therefore, maintaining rather than increasing hamstring strength postoperatively should be emphasized as an integral part of rehabilitation.

Effects of immobilization and subsequent low- and high-intensity exercise on morphology of rat calf muscles

After a cast immobilization of 3 weeks, the effects of 4-week remobilization by free cage activity or treadmill running on the morphology of the rat soleus and gastrocnemius muscles were studied. The studied morphometric parameters were: percentage volume of intramuscular connective tissue, capillary density, muscle fiber size, number of fibers with a pathological structural alteration, and fiber type distribution. In both muscles, immobilization of 3 weeks produced a significant increase in the connective tissue volume and number of fibers with pathological alterations, with a similar decrease in the capillary number and fiber size. At the same time, the relative amount of type I fibers decreased and type IIA fibers increased. Free remobilization and especially intensified remobilization by treadmill running significantly restored these values towards controls. These findings indicate that in rat soleus and gastrocnemius muscles immobilization-induced accumulation of intramuscular connective tissue, capillary loss, reduction in fiber size, accumulation of fibers with pathological structural alterations, and changes in fiber type distribution are to a great extent reversible phenomena, especially if remobilization is intensified by physical training. In clinical practice, this suggests that in patients with musculoskeletal injuries the postimmobilization rehabilitation should be early and effective.

Three-dimensional structure of the vascular network in normal and immobilized muscles of the rat

OBJECTIVE

To examine whether there are three-dimensional changes in capillaries of rat soleus muscle during mechanical limb immobilization.

DESIGN

Scanning electron microscopy, with the microcorrosion cast technique, was used to examine vascular networks in immobilized Wistar rat soleus muscles from 4 to 12 weeks after limb immobilization and to compare these networks with those in the control muscle.

INTERVENTION

Immobilization of the soleus muscle was achieved by unilateral pinning of the ankle joint in full plantar flexion.

RESULTS

The wavelike structure of the vascular network in the control muscles changed into a straight configuration in 8- and 12-week immobilized muscles.

Impaired viscoelastic behaviour of spastic plantarflexors during passive stretch at different velocities

OBJECTIVE: The aim of this study was to evaluate the effect of velocity on non-reflexly induced resistive torque (RT) responses of the spastic plantarflexors (PFs) of subjects with spinal cord injuries. DESIGN: Descriptive study, transversal. BACKGROUND: In spastic muscles, non-reflex changes such as increased muscle stiffness, contractures and atrophy have been reported. These changes probably alter muscle tensile properties and viscoelastic behaviour. METHODS: Six subjects with chronic (1-3 yr) spinal cord injuries (SCI) and 12 normal controls (CTLs) participated in this study. Passive ankle dorsiflexions (DFs), ranging from -35 degrees to 5 degrees of DF, were randomly imposed at 5 degrees /s, 10 degrees /s, 20 degrees /s, 40 degrees /s, 60 degrees /s, 120 degrees /s and 180 degrees /s using an isokinetic dynamometer (Kin-Com(TM)). Unwanted muscle activity was detected using surface electrodes on the soleus and tibialis anterior muscles. RESULTS: The results show first that RT rose with increasing velocity; the RT increment reached statistical (analysis of variance (ANOVA); Scheffé post-hoc procedure) significance (P < 0.01) at a lower velocity for the CTLs (40 degrees /s) group than for the SCI group (60 degrees /s). Second, significantly (t-test; P < 0.001) larger net increments of RT (RT at each velocity minus RT at 5 degrees /s) were found for the CTLs at 180 degrees /s than for the SCI group whose RT plateaued at 60 degrees /s. Finally, whereas the RT-velocity relationship was linear (r = 0.94) in the CTLs, that of the SCI group followed a power regression model (r = 0.85). CONCLUSIONS: These results show that the spastic PFs of the subjects with SCIs have an impaired velocity-sensitive behaviour, especially at high velocities of stretch where greater resistance is expected.

Ankle ligament injuries

Images

Recovery of skeletal muscle after immobilization of rabbit hindlimb. A light microscopic study

The histopathology of the deep portion of the vastus intermedius (VIP) muscle from 13 rabbit hindlimbs immobilized in shortened position for 2-2.5 (n = 4), 3 (n = 3), 14 (n = 3) and 28 (n = 3) days and VIP muscles from 13 rabbit hindlimbs immobilized for the same time periods and subsequently remobilized for 4 weeks were compared. After 3 days of immobilization the VIP muscles displayed a 15% (p < 0.004) decline in muscle fibre diameter. By 2 weeks of immobilization fatty change was prominent and muscle fibre diameters had decreased to 56% (p < 0.0001) of control values. By 4 weeks of immobilization severe fibrotic damage of myofibres was observed and fibre diameters had decreased to 47% (p < 0.0001) of control values. Three days of immobilization followed by 4 weeks of remobilization led to marked fatty change as well as an increase in connective tissue in the affected VIP muscles. The muscle fibre diameter in these muscles was 71% (p < 0.0001) compared to the VIP immobilized for 3 days and 61% (p < 0.0001) compared to the control muscles. By 2-4 weeks of immobilization the subsequent remobilization did not aggravate the initial damage. We conclude that the morphology of VIP muscle immobilized for 3 days suffers more during a subsequent remobilization period than those immobilized for 14-28 days. These findings focus attention on the mechanisms operating at the onset of disuse muscle atrophy.

Effects of immobilization, three forms of remobilization, and subsequent deconditioning on bone mineral content and density in rat femora

Disuse is associated with bone loss, which may not be recoverable. It is not known whether intensified remobilization is beneficial in restoring disuse-related bone loss nor if any such benefit would depend upon continuing mobilization for its maintenance. After an immobilization period of 3 weeks, the effects of free remobilization (11 weeks), and low-and high-intensity treadmill running (11 weeks) with and without subsequent deconditioning (18 weeks) on the bone mineral content (BMC) and density (BMD) of the hindlimb femora of Sprague-Dawley rats (n = 98) were studied using a dual-energy X-ray absorptiometric (DXA) scanner. Our hypothesis was that intensified remobilization is beneficial in restoring the BMC and BMD from disuse to normal while subsequent deconditioning is deleterious to these parameters. Immobilization for 3 weeks produced a significant BMC and BMD loss in the immobilized left femur (range -4.4 to -12.8%; p < 0.05-0.001). In the groups with free remobilization (free cage activity), the body weight-adjusted BMCs and BMDs always remained below those in the controls (range -2.3 to -12.1%; p values ranging from NS to < 0.01). Both low- and high-intensity running restored BMC and BMD in the immobilized limb, the effect being better in the latter group. In both of these groups, the values of the immobilized left limbs and those of the free right limbs exclusively exceeded the corresponding values of the age-matched control rats (left limb values 3.0-21.1% higher with p values ranging from NS to < 0.01; right limb values 7.9-21.4% higher with p < 0.05-0.01). However, after the deconditioning period of 18 weeks, the above described beneficial effects of low- and high-intensity running were lost, the left and right limb BMC and BMD values being lower than those in the age-matched controls (range -3.8 to -8.7%; p values ranging from NS to < 0.05). In conclusion, this study clearly indicates the need for greater than normal activity to restore the BMC and BMD after disuse to normal levels. However, the benefits of intensified remobilization are lost if the activity is terminated, and therefore, after immobilization and disuse, bone loading activities should be continued, perhaps indefinitely.

Fatty degeneration in the supraspinatus muscle after rotator cuff tear

We studied the relationship between fatty degeneration in the supraspinatus muscle after rotator cuff tear and muscle atrophy and tendon retraction in 41 cadaveric shoulders. Eighteen shoulders had a supraspinatus tendon tear. Transverse sections of the supraspinatus muscle were made at the proximal end of the scapular notch. The tendon fiber areas were stained red and the muscle fiber areas were stained yellow by the van Gieson method. Areas of fatty degeneration were stained orange-red by the Sudan three method. These areas were measured with a computer color image analysis system. There were many areas of the fatty degenerative change in the supraspinatus muscles associated with a cuff tear, mainly around the tendon fibers and the vessels. The fatty degeneration in the supraspinatus muscle after cuff tear was found to have a strong association with the degree of retraction of the tendon fibers rather than the reduction of muscle volume.

Joint dependent passive stiffness in paretic and contralateral limbs of spastic patients with hemiparetic stroke

Torque-angle relations at the elbow and ankle joints of relaxed normal controls and patients with hemiparetic stroke were compared. Low velocity flexion/hold/extension angular perturbations were applied to the joint under examination. The resulting torque-angle profiles described a hysteresis loop with similar slopes during the extension and flexion stages but separated by a vertical torque offset. Torque-angle responses obtained in the absence of significant muscle activation, as recorded by surface electromyographic activity, were designated as passive. Elbow passive stiffness estimates were calculated from the slope of the torque-angle response during the flexion stage of the perturbation. The elbow torque-angle plots exhibited linear passive stiffness with magnitude significantly lower than the passive stiffness of the ankle in both normal subjects and spastic patients. Changing ramp velocity had no significant effect on the passive torque-angle hysteresis loop at the elbow. A comparison of the torque-angle relations between hemiparetic spastic and normal control arms showed no significant differences in passive stiffness. Furthermore, no significant differences were found between paretic and contralateral upper limbs of a given hemiparetic subject. By contrast, significant differences in the torque-angle hysteresis loop were present between the paretic and contralateral ankles in all hemiparetic patients tested. These differences were more significant during dorsiflexion, and therefore seem to be related to preferential changes in mechanical properties of plantar flexor muscles. It is hypothesised that the differences in the torque-angle hysteresis loop between elbow and angle joints are related primarily to the larger amount of connective tissue in the calf muscles, as well as to a larger total physiological cross sectional area of calf muscles compared with elbow muscles. It is further hypothesized that the preferential increases in passive stiffness at the ankle in spastic legs result from immobilisation induced changes in muscle connective tissue, which are most prominent in muscles with predominantly slow-twitch fibres (such as soleus). Connective tissue surrounding such slow twitch muscle fibres have been shown to be more sensitive to immobilisation than those in fast twitch muscle. The functional, pathophysiological, and clinical implications of our findings are reviewed.

Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo

Before studying the biomechanical effects of rehabilitation exercises on the reconstructed knee, it is important to understand their effects on the normal anterior cruciate ligament. The objective of this investigation was to measure the strain behavior of this ligament during rehabilitation activities in vivo. Participants were patient volunteers with normal anterior cruciate ligaments instrumented with the Hall effect transducer. At 10 degrees and 20 degrees of flexion, ligament strain values for active extension of the knee with a weight of 45 N applied to a subject's lower leg were significantly greater than active motion without the weight. Isometric quadriceps muscle contraction at 15 degrees and 30 degrees also produced a significant increase in ligament strain, while at 60 degrees and 90 degrees of knee flexion there was no change in ligament strain relative to relaxed muscle condition. Simultaneous quadriceps and hamstrings muscles contraction at 15 degrees produced a significant increase in ligament strain compared with the relaxed state but did not strain the ligament at 30 degrees, 60 degrees, and 90 degrees of flexion. Isometric contraction of hamstrings muscles did not produce change in ligament strain at any flexion angle. Exercises that produce low or unstrained ligament values, and would not endanger a properly implanted graft, are either dominated by the hamstrings muscle (isometric hamstring), involve quadriceps muscle activity with the knee flexed at 60 degrees or greater (isometric quadriceps, simultaneous quadriceps and hamstrings contraction), or involve active knee motion between 35 degrees and 90 degrees of flexion.

Effects of free mobilization and low- to high-intensity treadmill running on the immobilization-induced bone loss in rats

After an immobilization period of 3 weeks, the effects of free remobilization (8 weeks) as well as low- and high-intensity treadmill running on the bone mineral content (BMC) and density (BMD) of the hindlimbs of Sprague-Dawley rats (n = 70) were studied using a dual-energy x-ray absorptiometric scanner. In the low-intensity running program, the rats were allowed to move freely in the cage for 1 week, after which they started to run on a treadmill twice a day for 7 weeks. The speed of the treadmill was 20 cm/s, with an uphill inclination of 10 degrees. The running time was gradually increased from 20 minutes per session to 45 minutes per session. In the high-intensity group, the program was similar, with the exception that the speed of the treadmill was 30 cm/s, with an uphill inclination of 30 degrees. Immobilization for 3 weeks produced a significant BMC and BMD loss in the immobilized left femur and tibia (mean loss 9.6%, p < 0.001) but did not affect the right free limbs. Both low- and high-intensity running restored mineral content in the immobilized limb; however, an average 5% difference (p < 0.05) in mineral content of the right and left limb bones persisted. In the running groups, the values for the immobilized left limbs were at the same level or exceeded (range 3.8-11.6%, p < 0.05-0.01) and those of the free right limbs exclusively exceeded (range 5.3-15.9%, p < 0.05-0.01) the corresponding values of the age-matched control rats.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of immobilization on myotendinous junction: an ultrastructural, histochemical and immunohistochemical study

The effect of immobilization on the myotendinous junction of the calf muscles in the rat was studied histochemically, immunohistochemically and morphometrically with a transmission electron microscope. After 3 weeks of immobilization, the contact area between the muscle cells and tendineal collagen fibres was reduced by almost 50% in both type I (slow-twitch) and type II (fast-twitch) muscle fibres. The terminal finger-like processes of the muscle cells became shallow and cylindrical or were completely atrophied. Their basal membranes were slightly thickened. Histochemically, the most remarkable alteration in the myotendinous junction was the marked decrease in the sulphate containing glycosaminoglycans. In the basal lamina of the muscle fibres, the glycosaminoglycan and proteoglycan content was also reduced. Immunohistochemical analyses revealed that the amount of type III collagen was markedly increased on the myotendinous interface, but the amount and distribution of type I collagen was not affected by immobilization. These findings suggest that immobilization causes degenerative changes at the myotendinous junction, which, in turn, most likely decrease its tensile strength and may predispose it to rupture during activity.

Function of the quadriceps and hamstrings muscles in knees with chronic partial deficiency of the anterior cruciate ligament. Isometric and isokinetic evaluation

We assessed the isokinetic and isometric strength and power profile of the knees of 37 patients who had a previous grade II sprain (partial tear) of the anterior cruciate ligament. Of the 37 knees, 11 had an isolated partial anterior cruciate ligament rupture and 26 had a partial anterior cruciate ligament rupture combined with a partial medial collateral ligament rupture. The Cybex II isokinetic dynamometer was used in the measurements. Eight years after the injury, the mean strength deficit of the injured knees was minimal when compared with the uninjured side. In the hamstrings of both groups, the relative strength deficit increased significantly with a higher speed of isokinetic movement (P less than 0.05). Compared with the strength parameters (peak torques), the other functional parameters (total work, average power, and peak angular impulse) of the injured knees showed some, but not significantly greater, deficits (hamstrings, 7% to 10%; quadriceps, 4% to 10%). We found that the general thigh muscle function in knees with old grade II sprains of the anterior cruciate ligament appears adequate except in flexion where the strength deficits are significantly greater in higher speeds of isokinetic movement. Therefore, rehabilitation using high-speed flexion (and extension) exercises is recommended.