Cyclic loading alters biomechanical properties and secretion of PGE2 and NO from tendon explants

Mouse Achilles tendons exhibit collagen disorganization but minimal collagen denaturation during cyclic loading to failure

While overuse is a prominent risk factor for tendinopathy, the fatigue-induced structural damage responsible for initiating tendon degeneration remains unclear. Denaturation of collagen molecules and collagen fiber disorganization have been observed within certain tendons in response to fatigue loading. However, no studies have investigated whether these forms of tissue damage occur in Achilles tendons, which commonly exhibit tendinopathy. Therefore, the objective of this study was to determine whether mouse Achilles tendons undergo collagen denaturation and collagen fiber disorganization when cyclically loaded to failure. Consistent with previous testing of other energy-storing tendons, we found that cyclic loading of mouse Achilles tendons produced collagen disorganization but minimal collagen denaturation. To determine whether the lack of collagen denaturation is unique to mouse Achilles tendons, we monotonically loaded the Achilles and other mouse tendons to failure. We found that the patellar tendon was also resistant to collagen denaturation, but the flexor digitorum longus (FDL) tendon and tail tendon fascicles were not. Furthermore, the Achilles and patellar tendons had a lower tensile strength and modulus. While this may be due to differences in tissue structure, it is likely that the lack of collagen denaturation during monotonic loading in both the Achilles and patellar tendons was due to failure near their bony insertions, which were absent in the FDL and tail tendons. These findings suggest that mouse Achilles tendons are resistant to collagen denaturation in situ and that Achilles tendon degeneration may not be initiated by mechanically-induced damage to collagen molecules.

Valgus fatigue and nonlinear damage accretion of the anterior bundle of the elbow medial collateral ligament (AMCL)

Failure by fatigue is one mechanism by which ligaments can rupture, with the accumulation of damage gradually degrading the ligament strength. Baseball pitchers who perform repeated high-level throwing continuously subject the medial ligament complex of the elbow to extreme levels of loading, which can lead to fatigue and eventual rupture. This study sought to investigate this behavior and quantify the fatigue properties of the anterior bundle of the medial collateral ligament (AMCL) with respect to valgus elbow torque. Eleven pairs of cadaveric elbow specimens were used for this study. One side of each pair was tested in vertical elongation at four flexion angles and then tested to failure at 90° of flexion. The contralateral specimens were tested in valgus fatigue at 90° of flexion using a specialized apparatus with application of known moments based on the elongation failure load. The average tensile failure load for the AMCL was 595.3 ± 201.9 N. During cycling, the average increase in the maximum valgus rotation angle was 4.77° ± 2.82°. The average maximum stretch of the AMCL middle band increased from 1.066 ± 0.017 to 1.076 ± 0.018 near the time of fatigue failure. The average cycles to failure for specimens tested at 90% and 80% of the estimated failure torque were 3211 ± 4721.33 and 25063 ± 30487.58, respectively. The nonlinear non-dimensional fatigue life and damage accretion results work in conjunction to predict the fatigue properties for a valgus elbow motion of arbitrary torque magnitude at 90° of elbow flexion.

Inflammatory mechanisms linking obesity and tendinopathy

Chronic tendinopathy is a debilitating tendon disorder with disappointing treatment outcomes. This review focuses on the potential roles of chronic low-grade inflammation in promoting tendinopathy in obesity. A systematic literature search was performed to identify all clinical studies supporting the actions of obesity-associated inflammatory mediators in the development of tendinopathy. The mechanisms of obesity-induced chronic inflammation in adipose tissue are firstly reviewed. Common inflammatory mediators potentially linking obesity and the development of tendinopathy, and their association with mechanical overuse, are discussed, along with pre-clinical evidences and a systematic literature search on clinical studies. The potential contribution of local adipose tissues in the promotion of inflammation, pain and tendon degeneration is then discussed. The future research directions are proposed.

Translational potential statement

Better understanding of the roles of obesity-associated inflammatory mediators on tendons will clarify the pathophysiological drivers of tendinopathy in patients with obesity and identify possible treatment targets. Further studies on the mechanisms of obesity-induced chronic inflammation on tendon are a promising direction for the treatment of tendinopathy.

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.

A brief history of tendon and ligament bioreactors: Impact and future prospects

Bioreactors are powerful tools with the potential to model tissue development and disease in vitro. For nearly four decades, bioreactors have been used to create tendon and ligament tissue-engineered constructs in order to define basic mechanisms of cell function, extracellular matrix deposition, tissue organization, injury, and tissue remodeling. This review provides a historical perspective of tendon and ligament bioreactors and their contributions to this advancing field. First, we demonstrate the need for bioreactors to improve understanding of tendon and ligament function and dysfunction. Next, we detail the history and evolution of bioreactor development and design from simple stretching of explants to fabrication and stimulation of two- and three-dimensional constructs. Then, we demonstrate how research using tendon and ligament bioreactors has led to pivotal basic science and tissue-engineering discoveries. Finally, we provide guidance for new basic, applied, and clinical research utilizing these valuable systems, recognizing that fundamental knowledge of cell-cell and cell-matrix interactions combined with appropriate mechanical and chemical stimulation of constructs could ultimately lead to functional tendon and ligament repairs in the coming decades.

Impact of Uniaxial Stretching on Both Gliding and Traction Areas of Tendon Explants in a Novel Bioreactor

The effects of mechanical stress on cells and their extracellular matrix, especially in gliding sections of tendon, are still poorly understood. This study sought to compare the effects of uniaxial stretching on both gliding and traction areas in the same tendon. Flexor digitorum longus muscle tendons explanted from rats were subjected to stretching in a bioreactor for 6, 24, or 48 h, respectively, at 1 Hz and an amplitude of 2.5%. After stimulation, marker expression was quantified by histological and immunohistochemical staining in both gliding and traction areas. We observed a heightened intensity of scleraxis after 6 and 24 h of stimulation in both tendon types, though it had declined again 48 h after stimulation. We observed induced matrix metalloproteinase-1 and -13 protein expression in both tendon types. The bioreactor produced an increase in the mechanical structural strength of the tendon during the first half of the loading time and a decrease during the latter half. Uniaxial stretching of flexor tendon in our set-up can serve as an overloading model. A combination of mechanical and histological data allows us to improve the conditions for cultivating tendon tissues.

Different Frequency of Cyclic Tensile Strain Relates to Anabolic/Catabolic Conditions Consistent with Immunohistochemical Staining Intensity in Tenocytes

Tenocytes are mechanosensitive cells intimately adapting their expression profile and hence, their phenotype to their respective mechanomilieu. The immunolocalization and expression intensity of tenogenic, anabolic and catabolic markers in tenocytes in response to in vitro mechanical loading have not been monitored by immunohistochemical staining (IHC). Thus, we investigated the association between IHC intensities, different stimulation frequencies, and tenogenic metabolism using a versatile mechanical stretcher. Primary tenocytes obtained from murine Achilles tendons were transferred to poly(dimethylsiloxane) (PDMS) elastomeric chamber. Chambers were cyclically stretched by 5% in uniaxial direction at a variation of tensile frequency (1 or 2 Hz) for 3 h. After stretching, cell physiology, IHC intensities of tendon-related markers, and protein level of the angiogenesis marker vascular endothelial growth factor (VEGF) were evaluated. Cell proliferation in tenocytes stimulated with 1 Hz stretch was significantly higher than with 2 Hz or without stretch, while 2 Hz stretch induced significantly reduced cell viability and proliferation with microscopically detectable apoptotic cell changes. The amount of scleraxis translocated into the nuclei and tenomodulin immunoreactivity of tenocytes treated with stretch were significantly higher than of non-stretched cells. The collagen type-1 expression level in tenocytes stretched at 1 Hz was significantly higher than in those cultivated with 2 Hz or without stretching, whereas the matrix metalloproteinase (MMP)-1 and MMP-13 immunoreactivities of cells stretched at 2 Hz were significantly higher than in those stimulated with 1 Hz or without stretching. The secreted VEGF-protein level of tenocytes stretched at 2 Hz was significantly higher than without stretching. Our IHC findings consistent with cell physiology suggest that appropriate stretching can reproduce in vitro short-term tenogenic anabolic/catabolic conditions and allow us to identify an anabolic stretching profile.

Tendon explant models for physiologically relevant invitro study of tissue biology - a perspective

Background: Tendon disorders increasingly afflict our aging society but we lack the scientific understanding to clinically address them. Clinically relevant models of tendon disease are urgently needed as established small animal models of tendinopathy fail to capture essential aspects of the disease. Two-dimensional and three-dimensional cell and tissue culture models are similarly limited, lacking many physiological extracellular matrix cues required to maintain tissue homeostasis or guide matrix remodeling. These cues reflect the biochemical and biomechanical status of the tissue, and encode information regarding the mechanical and metabolic competence of the tissue. Tendon explants overcome some of these limitations and have thus emerged as a valuable tool for the discovery and study of mechanisms associated with tendon homeostasis and pathophysiology. Tendon explants retain native cell-cell and cell-matrix connections, while allowing highly reproducible experimental control over extrinsic factors like mechanical loading and nutritional availability. In this sense tendon explant models can deliver insights that are otherwise impossible to obtain from in vivo animal or in vitro cell culture models. Purpose: In this review, we aimed to provide an overview of tissue explant models used in tendon research, with a specific focus on the value of explant culture systems for the controlled study of the tendon core tissue. We discuss their advantages, limitations and potential future utility. We include suggestions and technical recommendations for the successful use of tendon explant cultures and conclude with an outlook on how explant models may be leveraged with state-of-the-art biotechnologies to propel our understanding of tendon physiology and pathology.

Biomaterials to Mimic and Heal Connective Tissues

Connective tissue is one of the four major types of animal tissue and plays essential roles throughout the human body. Genetic factors, aging, and trauma all contribute to connective tissue dysfunction and motivate the need for strategies to promote healing and regeneration. The goal here is to link a fundamental understanding of connective tissues and their multiscale properties to better inform the design and translation of novel biomaterials to promote their regeneration. Major clinical problems in adipose tissue, cartilage, dermis, and tendon are discussed that inspire the need to replace native connective tissue with biomaterials. Then, multiscale structure-function relationships in native soft connective tissues that may be used to guide material design are detailed. Several biomaterials strategies to improve healing of these tissues that incorporate biologics and are biologic-free are reviewed. Finally, important guidance documents and standards (ASTM, FDA, and EMA) that are important to consider for translating new biomaterials into clinical practice are highligted.

Dynamic Loading and Tendon Healing Affect Multiscale Tendon Properties and ECM Stress Transmission

The extracellular matrix (ECM) is the primary biomechanical environment that interacts with tendon cells (tenocytes). Stresses applied via muscle contraction during skeletal movement transfer across structural hierarchies to the tenocyte nucleus in native uninjured tendons. Alterations to ECM structural and mechanical properties due to mechanical loading and tissue healing may affect this multiscale strain transfer and stress transmission through the ECM. This study explores the interface between dynamic loading and tendon healing across multiple length scales using living tendon explants. Results show that macroscale mechanical and structural properties are inferior following high magnitude dynamic loading (fatigue) in uninjured living tendon and that these effects propagate to the microscale. Although similar macroscale mechanical effects of dynamic loading are present in healing tendon compared to uninjured tendon, the microscale properties differed greatly during early healing. Regression analysis identified several variables (collagen and nuclear disorganization, cellularity, and F-actin) that directly predict nuclear deformation under loading. Finite element modeling predicted deficits in ECM stress transmission following fatigue loading and during healing. Together, this work identifies the multiscale response of tendon to dynamic loading and healing, and provides new insight into microenvironmental features that tenocytes may experience following injury and after cell delivery therapies.

Fatigue damage of collagenous tissues: experiment, modeling and simulation studies

Mechanical fatigue damage is a critical issue for soft tissues and tissue-derived materials, particularly for musculoskeletal and cardiovascular applications; yet, our understanding of the fatigue damage process is incomplete. Soft tissue fatigue experiments are often difficult and time-consuming to perform, which has hindered progress in this area. However, the recent development of soft-tissue fatigue-damage constitutive models has enabled simulation-based fatigue analyses of tissues under various conditions. Computational simulations facilitate highly controlled and quantitative analyses to study the distinct effects of various loading conditions and design features on tissue durability; thus, they are advantageous over complex fatigue experiments. Although significant work to calibrate the constitutive models from fatigue experiments and to validate predictability remains, further development in these areas will add to our knowledge of soft-tissue fatigue damage and will facilitate the design of durable treatments and devices. In this review, the experimental, modeling, and simulation efforts to study collagenous tissue fatigue damage are summarized and critically assessed.

The Biology of Bone and Ligament Healing

This review describes the normal healing process for bone, ligaments, and tendons, including primary and secondary healing as well as bone-to-bone fusion. It depicts the important mediators and cell types involved in the inflammatory, reparative, and remodeling stages of each healing process. It also describes the main challenges for clinicians when trying to repair bone, ligaments, and tendons with a specific emphasis on Charcot neuropathy, fifth metatarsal fractures, arthrodesis, and tendon sheath and adhesions. Current treatment options and research areas are also reviewed.

The (dys)functional extracellular matrix

The extracellular matrix (ECM) is a major component of the biomechanical environment with which cells interact, and it plays important roles in both normal development and disease progression. Mechanical and biochemical factors alter the biomechanical properties of tissues by driving cellular remodeling of the ECM. This review provides an overview of the structural, compositional, and mechanical properties of the ECM that instruct cell behaviors. Case studies are reviewed that highlight mechanotransduction in the context of two distinct tissues: tendons and the heart. Although these two tissues demonstrate differences in relative cell-ECM composition and mechanical environment, they share similar mechanisms underlying ECM dysfunction and cell mechanotransduction. Together, these topics provide a framework for a fundamental understanding of the ECM and how it may vary across normal and diseased tissues in response to mechanical and biochemical cues. This article is part of a Special Issue entitled: Mechanobiology.

Early stage fatigue damage occurs in bovine tendon fascicles in the absence of changes in mechanics at either the gross or micro-structural level

Many tendon injuries are believed to result from repetitive motion or overuse, leading to the accumulation of micro-damage over time. In vitro fatigue loading can be used to characterise damage during repeated use and investigate how this may relate to the aetiology of tendinopathy.

This study considered the effect of fatigue loading on fascicles from two functionally distinct bovine tendons: the digital extensor and deep digital flexor. Micro-scale extension mechanisms were investigated in fascicles before or after a period of cyclic creep loading, comparing two different measurement techniques – the displacement of a photo-bleached grid and the use of nuclei as fiducial markers.

Whilst visual damage was clearly identified after only 300 cycles of creep loading, these visual changes did not affect either gross fascicle mechanics or fascicle microstructural extension mechanisms over the 900 fatigue cycles investigated. However, significantly greater fibre sliding was measured when observing grid deformation rather than the analysis of nuclei movement. Measurement of microstructural extension with both techniques was localised and this may explain the absence of change in microstructural deformation in response to fatigue loading. Alternatively, the data may demonstrate that fascicles can withstand a degree of matrix disruption with no impact on mechanics. Whilst use of a photo-bleached grid to directly measure the collagen is the best indicator of matrix deformation, nuclei tracking may provide a better measure of the strain perceived directly by the cells.

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Tendon fascicle gross mechanics and micro-scale deformation investigated after fatigue loading.

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Fascicles can withstand a degree of matrix disruption without impact on mechanics.

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More fibre sliding was observed measuring grid deformation than tracking nuclei.

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Nuclei tracking may better represent the strains experienced by cells than grid deformation.

Prediction of the elastic strain limit of tendons

The elastic strain limit (ESL) of tendons is the point where maximum elastic modulus is reached, after which micro-damage starts. Study of damage progression in tendons under repetitive (fatigue) loading requires a priori knowledge about ESL. In this study, we propose three different approaches for predicting ESL. First, one single value is assumed to represent the ESL of all tendon specimens. Second, different extrapolation curves are used for extrapolating the initial part of the stress-strain curve. Third, a method based on comparing the shape of the initial part of the stress-strain curve of specimens with a database of stress-strain curves is used. A large number of porcine tendon explants (97) were tested to examine the above-mentioned approaches. The variants of the third approach yielded significantly (p<0.05) smaller error values as compared to the other approaches. The mean absolute percentage error of the best-performing variant of the shape-based comparison was between 8.14±6.44% and 9.96±9.99% depending on the size of the initial part of the stress-strain curves. Interspecies generalizability of the best performing method was also studied by applying it for prediction of the ESL of horse tendons. The ESL of horse tendons was predicted with mean absolute percentage errors ranging between 10.53±7.6% and 19.16±14.31% depending on the size of the initial part of the stress-strain curves and the type of normalization. The results of this study suggest that both ESL and the shape of stress-strain curves may be highly different between different individuals and different anatomical locations.

Healing of subcutaneous tendons: Influence of the mechanical environment at the suture line on the healing process

Tendon ruptures remain a significant musculoskeletal injury. Despite advances in surgical techniques and procedures, traditional repair techniques maintain a high incidence of rerupture or tendon elongation. Mechanical loading and biochemical signaling both control tissue healing. This has led some researchers to consider using a technique based on tension regulation at the suture line for obtaining good healing. However, it is unknown how they interact and to what extent mechanics control biochemistry. This review will open the way for understanding the interplay between mechanical loading and the process of tendon healing.

Fatigue loading of tendon

Tendon injuries, often called tendinopathies, are debilitating and painful conditions, generally considered to develop as a result of tendon overuse. The aetiology of tendinopathy remains poorly understood, and whilst tendon biopsies have provided some information concerning tendon appearance in late-stage disease, there is still little information concerning the mechanical and cellular events associated with disease initiation and progression. Investigating this in situ is challenging, and numerous models have been developed to investigate how overuse may generate tendon fatigue damage and how this may relate to tendinopathy conditions. This article aims to review these models and our current understanding of tendon fatigue damage. We review the strengths and limitations of different methodologies for characterizing tendon fatigue, considering in vitro methods that adopt both viable and non-viable samples, as well as the range of different in vivo approaches. By comparing data across model systems, we review the current understanding of fatigue damage development. Additionally, we compare these findings with data from tendinopathic tissue biopsies to provide some insights into how these models may relate to the aetiology of tendinopathy. Fatigue-induced damage consistently highlights the same microstructural, biological and mechanical changes to the tendon across all model systems and also correlates well with the findings from tendinopathic biopsy tissue. The multiple testing routes support matrix damage as an important contributor to tendinopathic conditions, but cellular responses to fatigue appear complex and often contradictory.

Phosphoinositide 3-kinase/Akt signaling is essential for prostaglandin E2-induced osteogenic differentiation of rat tendon stem cells

Tissue calcification is a typical histopathological feature of tendinopathy. The osteogenic differentiation of tendon stem cells (TSCs) induced by inflammatory mediators is believed to play a key role in this process. Previous studies showed that the major inflammatory mediator prostaglandin E2 (PGE2) induced osteogenic differentiation of TSCs via bone morphogenetic protein (BMP)-2 production. Using a rat TSC culture model, we showed that PGE2 induced BMP-2 production through up-regulation of BMP-2 mRNA expression. PGE2 activated Akt, but not extracellular-signal-regulated kinase, in TSCs. Increased BMP-2 mRNA expression mediated by PGE2 was prevented by phosphoinositide 3-kinase (PI3K) and Akt inhibitors, but not by a MEK inhibitor. Furthermore, in the presence of exogenous BMP-2, PI3K and Akt inhibitors blocked Runx2 and osteocalcin expression, although BMP-2 did not activate Akt. BMP-2-induced alkaline phosphatase activity and mineralization were also inhibited by PI3K and Akt inhibitors. However, these inhibitors did not block activation of Smad, implying that Akt was involved downstream of Smad. Taken together, these results indicate that the PI3K-Akt signaling cascade is essential for PGE2-induced BMP-2 production and BMP-2-mediated osteogenic differentiation, suggesting that PI3-kinase-Akt signaling contributes to the formation of calcified tissues in tendinopathy.

The pathogenesis of tendon microdamage in athletes: the horse as a natural model for basic cellular research

The equine superficial digital flexor tendon (SDFT) is a frequently injured structure that is functionally and clinically equivalent to the human Achilles tendon (AT). Both act as critical energy-storage systems during high-speed locomotion and can accumulate exercise- and age-related microdamage that predisposes to rupture during normal activity. Significant advances in understanding of the biology and pathology of exercise-induced tendon injury have occurred through comparative studies of equine digital tendons with varying functions and injury susceptibilities. Due to the limitations of in-vivo work, determination of the mechanisms by which tendon cells contribute to and/or actively participate in the pathogenesis of microdamage requires detailed cell culture modelling. The phenotypes induced must ultimately be mapped back to the tendon tissue environment. The biology of tendon cells and their matrix, and the pathological changes occurring in the context of early injury in both horses and people are reviewed, with a particular focus on the use of various tendon cell and tissue culture systems to model these events.

Effect of prostaglandin E2 injection on the structural properties of the rat patellar tendon

Background

Increased tendon production of the inflammatory mediator prostaglandin E₂ (PGE₂) has been suggested to be a potential etiologic agent in the development of tendinopathy. Repeated injection of PGE₂ into tendon has been proposed as a potential animal model for studying treatments for tendinopathy. In contrast, nonsteroidal anti-inflammatory drugs (NSAIDs) which inhibit PGE₂ production and are commonly prescribed in treating tendinopathy have been shown to impair the healing of tendon after acute injury in animal models. The contradictory literature suggests the need to better define the functional effects of PGE₂ on tendon. Our objective was to characterize the effects of PGE₂ injection on the biomechanical and biochemical properties of tendon and the activity of the animals. Our hypothesis was that weekly PGE₂ injection to the rat patellar tendon would lead to inferior biomechanical properties.

Methods

Forty rats were divided equally into four groups. Three groups were followed for 4 weeks with the following peritendinous injection procedures: No injection (control), 4 weekly injections of saline (saline), 4 weekly injections of 800 ng PGE₂ (PGE₂-4 wks). The fourth group received 4 weekly injections of 800 ng PGE₂ initially and was followed for a total of 8 weeks. All animals were injected bilaterally. The main outcome measurements included: the structural and material properties of the patellar tendon under tensile loading to failure, tendon collagen content, and weekly animal activity scores.

Results

The ultimate load of PGE₂-4 wks tendons at 4 weeks was significantly greater than control or saline group tendons. The stiffness and elastic modulus of the PGE₂ injected tendons at 8 weeks was significantly greater than the control or saline tendons. No differences in animal activity, collagen content, or mean fibril diameter were observed between groups.

Conclusions

Four weekly peritendinous injections of PGE₂ to the rat patellar tendon were not found to be an effective model of clinical tendinopathy. In contrast, improved structural and material properties of the patellar tendon were found after PGE₂ injection. While PGE₂ has been thought to have a contributory role in the development of tendinopathy and anti-inflammatory medications remain a common treatment, our results suggest a positive role of PGE₂ in tendon remodeling in some circumstances.

BMP-2 mediates PGE(2) -induced reduction of proliferation and osteogenic differentiation of human tendon stem cells

Tendon stem cells (TSCs) have been proposed to play a major role in the development of tendinopathy, which refers to pathological changes, such as calcification, in affected tendons. Using a human TSC (hTSC) culture model, this study investigated the effects of PGE(2) , an inflammatory mediator present in injured tendons, on hTSC proliferation and differentiation as well as the molecular mediator for such PGE(2) -induced effects. We found that PGE(2) treatment of hTSCs decreased cell proliferation and caused osteogenic differentiation of hTSCs in a dose-dependent manner. Also, PGE(2) treatment of hTSCs induced dose-dependent BMP-2 production in culture, and moreover, addition of BMP-2 to hTSC culture decreased cell proliferation and induced hTSC differentiation into osteoblasts. Finally, addition of BMP-2 antibodies to hTSC culture treated with PGE(2) nearly abolished PGE(2) effects on both cell proliferation and osteogenic differentiation. Taken together, the findings of this study showed that BMP-2 mediates PGE(2) -induced reduction of proliferation and osteogenic differentiation of hTSCs. We suggest that such a mechanism may be partially responsible for the formation of calcified tissues in tendinopathic tendons seen in clinical settings.

Influence of a single loading episode on gene expression in healing rat Achilles tendons

Mechanical loading stimulates tendon healing via mechanisms that are largely unknown. Genes will be differently regulated in loaded healing tendons, compared with unloaded, just because of the fact that healing processes have been changed. To avoid such secondary effects and study the effect of loading per se, we therefore studied the gene expression response shortly after a single loading episode in otherwise unloaded healing tendons. The Achilles tendon was transected in 30 tail-suspended rats. The animals were let down from the suspension to load their tendons on a treadmill for 30 min once, 5 days after tendon transection. Gene expression was studied by Affymetrix microarray before and 3, 12, 24, and 48 h after loading. The strongest response in gene expression was seen 3 h after loading, when 150 genes were up- or downregulated (fold change ≥2, P ≤ 0.05). Twelve hours after loading, only three genes were upregulated, whereas 38 were downregulated. Fewer than seven genes were regulated after 24 and 48 h. Genes involved in the inflammatory response were strongly regulated at 3 and 12 h after loading; this included upregulation of iNOS, PGE synthase, and IL-1β. Also genes involved in wound healing/coagulation, angiogenesis, and production of reactive oxygen species were strongly regulated by loading. Microarray results were confirmed for 16 selected genes in a repeat experiment (N = 30 rats) using real-time PCR. It was also confirmed that a single loading episode on day 5 increased the strength of the healing tendon on day 12. In conclusion, the fact that there were hardly any regulated genes 24 h after loading suggests that optimal stimulation of healing requires a mechanical loading stimulus every day.

What are the validated animal models for tendinopathy?

Chronic tendinopathy refers to a broad spectrum of pathological conditions in tendons and their insertion, with symptoms including activity-related chronic pain. To study the pathogenesis and management strategies of chronic tendinopathy, studies in animal models are essential. The different animal models in the literature present advantages and limitations, and there is no consensus regarding the criteria of a universal tendinopathy animal model. Based on the review of literature and the discussion in the International Symposium on Ligaments and Tendons-X, we concluded that established clinical, histopathological and functional characteristics of human tendinopathy were all important and relevant criteria to be met, if possible, by animal models. As tendinopathy is a progressive, multifactorial tendon disorder affecting different anatomical structures, it may not be realistic to expect a single animal model to study all aspects of tendinopathy. Staging of tendinopathy over time and clearer definition of tendinopathies in relation to severity and type would enable realistic targets with any animal model. The existing animal models can be used for answering specific questions (horses for courses) but should not be used to conclude the general aspects of tendinopathy neither in animals nor in human.

The involvement of interleukin-1 and interleukin-4 in the response of human annulus fibrosus cells to cyclic tensile strain: an altered mechanotransduction pathway with degeneration

Introduction

Recent evidence suggests that intervertebral disc (IVD) cells derived from degenerative tissue are unable to respond to physiologically relevant mechanical stimuli in the 'normal' anabolic manner, but instead respond by increasing matrix catabolism. Understanding the nature of the biological processes which allow disc cells to sense and respond to mechanical stimuli (a process termed 'mechanotransduction') is important to ascertain whether these signalling pathways differ with disease. The aim here was to investigate the involvement of interleukin (IL)-1 and IL-4 in the response of annulus fibrosus (AF) cells derived from nondegenerative and degenerative tissue to cyclic tensile strain to determine whether cytokine involvement differed with IVD degeneration.

Methods

AF cells were isolated from nondegenerative and degenerative human IVDs, expanded in monolayers and cyclically strained in the presence or absence of the cytokine inhibitors IL-1 receptor antagonist (IL-1Ra) or IL-4 receptor antibody (IL-4RAb) with 10% strain at 1.0 Hz for 20 minutes using a Flexcell strain device. Total RNA was extracted from the cells at time points of baseline control and 1 or 24 hours poststimulation. Quantitative real-time polymerase chain reaction was used to analyse the gene expression of matrix proteins (aggrecan and type I collagen) and enzymes (matrix metalloproteinase 3 (MMP3) and a disintegrin and metalloproteinase with a thrombospondin type 1 motif 4 (ADAMTS4)).

Results

Expression of catabolic genes (MMP3 and ADAMTS4) decreased in AF cells derived from nondegenerative tissue in response to 1.0-Hz stimulation, and this decrease in gene expression was inhibited or increased following pretreatment of cells with IL-1Ra or IL-4RAb respectively. Treatment of AF cells derived from degenerative tissue with an identical stimulus (1.0-Hz) resulted in reduced anabolic gene expression (aggrecan and type I collagen), with IL-1Ra or IL-4RAb pretreatment having no effect.

Conclusions

Both IL-1 and IL-4 are involved in the response of AF cells derived from nondegenerative tissue to 1.0-Hz cyclic tensile strain. Interestingly, the altered response observed at 1.0-Hz in AF cells from degenerative tissue appears to be independent of either cytokine, suggesting an alternative mechanotransduction pathway in operation.

Deciphering the pathogenesis of tendinopathy: a three-stages process

Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments.

Functional analysis of tenocytes gene expression in tendon fascicles subjected to cyclic tensile strain

Tenocytes are known to be mechanoresponsive and the present study tests the hypothesis that distinct mechanical stimulation regimes, associated with the short-term and extended application of cyclic tensile strain, alters the balance between anabolic and catabolic processes. Microarray technology has been used to provide a comprehensive analysis of alterations in gene expression within isolated tendon fascicles in response to cyclic tensile strain using a well-established model system. Isolated rat tail tendon fascicles were subjected to cyclic tensile strain (3% amplitude superimposed on a 2% static strain) for 1 or 24 hr. Messenger RNA expression level was assessed using Illumina microarray. The number of genes significantly altered in strained fascicles from the level of unstrained control fascicles was greater at 24 hr than 1 hr. The expression levels of many extracellular matrix components remained unchanged at both time points; however, a number of members of the matrix metalloproteinase (MMP) and a disintegrin and metalloproteinase with a thrombospondin (ADAMTS) families were significantly downregulated at 24 hr. Functional annotation revealed that upregulated genes were significantly associated with the regulation of transcription at 1 hr and translation at 24 hr. Downregulated genes were associated with inflammatory responses at 1 hr, and genes inhibited at 24 hr were significantly associated with cell apoptosis and a variety of metabolic functions. The present results suggest that the metabolic balance was shifted in favor of catabolism by the application of a small number of tensile strain cycles, whereas an extended number stimulates strong anti-catabolic effects.

Prostaglandin E(2), collagenase, and cell death responses depend on cyclical load magnitude in an explant model of tendinopathy

Tendinopathy is a significant clinical problem that can result from repetitive activity. While the precise etiology of this condition remains unclear, the cellular response to cyclical loading is believed to have a contributory role to the pathology of tendinopathy. This study examined the short-term biochemical response of avian flexor digitorum profundus tendon to repetitive cyclic loadings of varying magnitude. An in vitro tendon explant model was utilized to apply four levels of haversine tensile stress (peak stress of 0, 3, 12, and 18 MPa) at 1.0 Hz, 8 hr/day for 3 days. The 12 and 18 MPa levels were known to cause significant mechanical damage based on previous work. Tissue media was recovered and analyzed for prostaglandin E(2) (PGE(2)), lactate dehydrogenase (LDH, measure of cell death), and collagenase levels. Tissue samples were recovered and analyzed for cell viability, total collagen, and sulfated glycosaminoglycan content. Collagenase, LDH, and PGE(2) levels were found to be influenced by loading magnitude (p < 0.05) with higher levels being present at higher load magnitudes. Varying cyclical load magnitude caused minimal compositional changes as collagen content and glycosaminoglycan did not change. These results indicate that elevated cyclical mechanical loading of tendon quickly results in altered biochemical tissue responses indicative of tissue injury. More sustained cyclical loading over time may be required for these initial responses to induce more dramatic tissue changes as observed in clinical tendinopathy.

[Tenocytes and the extracellular matrix : a reciprocal relationship]

The characteristic cells in tendons and ligaments are called tenocytes, which are responsible for the formation and turnover of the extracellular matrix. They react to external stimuli and facilitate the functional adaptation of the proteoglycan and collagen network to mechanical requirements. Via numerous cellular processes they form a complex communicating network which demonstrates coordinated directional reactions. As is common to all tissues in the human body, tendons are subject to age changes which influence the tenocytes, but additionally the structural organization and hence the function of the extracellular matrix. The function and organization of tendons are also affected by mechanical forces, as well as by various cytokines produced in the tissue and by the application of anti-inflammatory medication.

Differential regulation of gene expression in isolated tendon fascicles exposed to cyclic tensile strain in vitro

Mechanical stimulus is a regulator of tenocyte metabolism. The present study investigated temporal regulation of the expression of selected genes by tenocytes in isolated fascicles subjected to tensile strain in vitro. Cyclic tensile strain with a 3% amplitude superimposed on a 2% static strain was provided for 10 min, followed by either an unstrained period or continuous cyclic strain until the end of a 24-h incubation period. mRNA expression of selected anabolic and catabolic genes were evaluated with quantitative PCR at 10 min, 1 h, 6 h, and 24 h. The application of 6-h cyclic strain significantly upregulated type III collagen mRNA expression in strained fascicles compared with unstrained controls, but no alterations were observed in mRNA expression of type I collagen and biglycan. Significant downregulation in the expression of the decorin core protein was observed in fascicles subjected to 24-h cyclic strain. MMP3 and MMP13 expression levels were upregulated by the application of 10 min of cyclic strain, followed by a progressive downregulation until the end of the incubation period in both the absence and the presence of the continuing cyclic strain. Accordingly, alterations in the expression of anabolic genes were limited to the upregulation of type III collagen by prolonged exposure to cyclic strain, whereas catabolic genes were upregulated by a small number of strain cycles and downregulated by a prolonged cyclic strain. These findings demonstrate distinctive patterns of mechanoregulation for anabolic and catabolic genes and help our understanding of tenocyte response to mechanical stimulation.

Coordinate regulation of IL-1beta and MMP-13 in rat tendons following subrupture fatigue damage

Mechanical overloading is a major causative factor of tendinopathy; however, its underlying mechanisms are unclear. We hypothesized mechanical overloading would damage tendons and alter genes associated with tendinopathy in a load-dependent manner. To test this hypothesis, we fatigue loaded rat patellar tendons in vivo and measured expression of the matrix-degrading enzyme MMP-13 and the inflammatory cytokine IL-1beta. We also examined these responses in cultured tenocytes exposed to intermittent hydrostatic pressure in vitro. Additionally, we hypothesized load-induced changes in tenocyte MMP-13 expression would be dependent on expression of IL-1beta. In vivo fatigue loading at 1.7% strain caused overt microstructural damage and upregulated expression of MMP-13 and IL-1beta, while 0.6% strain produced only minor changes in matrix microstructure and downregulated expression of both MMP-13 and IL-1beta. Loading of cultured tenocytes at 2.5 and 7.5 MPa produced comparable changes in expression to those of in vivo tendon loading. Blocking IL-1beta expression with siRNA suppressed load-induced both MMP-13 mRNA expression and activity. The data suggest fatigue loading alters expression of MMP-13 and IL-1beta in tendons in vivo and tenocytes in vitro in a load-dependent manner. The data also suggest MMP-13 is regulated by both IL-1beta-dependent and IL-1beta-independent pathways.

Relaxation of the mouse pubic symphysis during late pregnancy is not accompanied by the influx of granulocytes

In some animals, such as mice and guinea pigs, a hormonally controlled mechanism increases the flexibility of the pubic symphysis and enhances the cervical remodeling necessary for safe delivery. Cervical ripening during pregnancy is associated with a paradoxical influx of leukocytes. However, the changes in cell metabolism during relaxation of the mouse pubic symphysis for delivery have not been extensively studied. In this work, we used light microscopy and transmission and scanning electron microcopy, as well as immunohistochemistry and Western blotting for MMP-8, to investigate the involvement of granulocytes or resident stromal cells in the relaxation of the virgin pubic symphysis during late pregnancy (days 18 and 19, before delivery) in vivo and in explanted joints. MMP-8 was studied because this collagenase is a hallmark for cervical ripening associated with the influx of granulocytes during late pregnancy. Extensive dissolution and disorganization of the extracellular matrix was seen around fibroblastic-like cells in late pregnancy. In contrast to the cervix (positive control), morphological and immunohistochemical analyses revealed that there was no characteristic cellular inflammatory response in the interpubic tissue. Staining for MMP-8 was observed in chondroid and fibroblastic-like cells of virgin and relaxed interpubic ligament, respectively. However, no granulocytes were seen during the extensive remodeling of the pubic joint in late pregnancy. These results indicate that constitutive stromal cells may have an important role in tissue relaxation during remodeling of the pubic symphysis in pregnancy.

Structure-function relationships in tendons: a review

The purpose of the current review is to highlight the structure-function relationship of tendons and related structures to provide an overview for readers whose interest in tendons needs to be underpinned by anatomy. Because of the availability of several recent reviews on tendon development and entheses, the focus of the current work is primarily directed towards what can best be described as the 'tendon proper' or the 'mid-substance' of tendons. The review covers all levels of tendon structure from the molecular to the gross and deals both with the extracellular matrix and with tendon cells. The latter are often called 'tenocytes' and are increasingly recognized as a defined cell population that is functionally and phenotypically distinct from other fibroblast-like cells. This is illustrated by their response to different types of mechanical stress. However, it is not only tendon cells, but tendons as a whole that exhibit distinct structure-function relationships geared to the changing mechanical stresses to which they are subject. This aspect of tendon biology is considered in some detail. Attention is briefly directed to the blood and nerve supply of tendons, for this is an important issue that relates to the intrinsic healing capacity of tendons. Structures closely related to tendons (joint capsules, tendon sheaths, pulleys, retinacula, fat pads and bursae) are also covered and the concept of a 'supertendon' is introduced to describe a collection of tendons in which the function of the whole complex exceeds that of its individual members. Finally, attention is drawn to the important relationship between tendons and fascia, highlighted by Wood Jones in his concept of an 'ectoskeleton' over half a century ago - work that is often forgotten today.

Cyclic loading inhibits expression of MMP-3 but not MMP-1 in an in vitro rabbit flexor tendon model

BACKGROUND

Gene expression analysis is useful for assessing cellular behavior and may improve our understanding of the initial cellular response to mechanical load leading to tendon degeneration. This study assessed gene expression of MMP-1 and MMP-3, genes associated with matrix degradation, in tendons exposed to cyclic loads within physiologic range.

METHODS

Six flexor tendons from each of ten New Zealand White rabbits were harvested and randomly assigned to one of the following six groups: load deprived for 18h; cyclically loaded for 18h to a peak stress of 2MPa; 3MPa; 4MPa; 5MPa; or snap frozen in liquid nitrogen. MMP-1, MMP-3 and 18s mRNA expression was measured by qRT-PCR.

FINDINGS

No significant differences in MMP-1 mRNA expression levels were found between loading groups. MMP-3 expression was significantly inhibited (57%) in tendons cyclically loaded to a peak stress of 4MPa in comparison to load deprived tendons, however, when peak stress was increased to 5MPa, expression was no longer significantly lower compared to stress shielded tendons.

INTERPRETATION

The results suggest a 'U' shape relationship between load and MMP-3 expression. The lack of change in MMP-1 expression with loading was unexpected as inhibition of MMP-1 in response to mechanical load has been demonstrated in previous studies. In conclusion, we demonstrate that MMP-3 expression is modulated by cyclic load and is sensitive to load magnitude. MMP-1 mRNA expression is not significantly modulated by cyclic load in this model.

Mechanobiology of adult and stem cells

Mechanical forces, including gravity, tension, compression, hydrostatic pressure, and fluid shear stress, play a vital role in human physiology and pathology. They particularly influence extracellular matrix (ECM) gene expression, ECM protein synthesis, and production of inflammatory mediators of many load-sensitive adult cells such as fibroblasts, chondrocytes, smooth muscle cells, and endothelial cells. Furthermore, the mechanical forces generated by cells themselves, known as cell traction forces (CTFs), also influence many biological processes such as wound healing, angiogenesis, and metastasis. Thus, the quantitative characterization of CTFs by qualities such as magnitude and distribution is useful for understanding physiological and pathological events at the tissue and organ levels. Recently, the effects of mechanical loads on embryonic and adult stem cells in terms of self-renewal, differentiation, and matrix protein expression have been investigated. While it seems certain that mechanical loads applied to stem cells regulate their self-renewal and induce controlled cell lineage differentiation, the detailed molecular signaling mechanisms responsible for these mechano-effects remain to be elucidated. Challenges in the fields of both adult- and stem-cell mechanobiology include devising novel experimental and theoretical methodologies to examine mechano-responses more closely to various forms of mechanical forces and mechanotransduction mechanisms of these cells in a more physiologically accurate setting. Such novel methodologies will lead to better understanding of various pathological diseases, their management, and translational applications in the ever expanding field of tissue engineering.

Time dependence of cyclic tensile strain on collagen production in tendon fascicles

Mechanical loading is a regulator of tissue metabolism in tendon, which may lead to alterations in structural and mechanical properties via mechanotransduction processes. The present study investigated specified responses of tenocyte metabolism in isolated tendon fascicles subjected to four loading regimes. Cyclic tensile strain of 3% amplitude superimposed on a 2% static strain was applied to the fascicles for 10min, 1, 6 or 24h of a 24-h incubation period. Collagen synthesis, assessed by [(3)H]-proline incorporation, was upregulated by the 24h straining regime, but was inhibited by the 10-min regime. Cyclic strain enhanced the retention of newly synthesised collagen within the matrix. More than 90% of the newly synthesised collagen was retained in all cases, but the long-term application of cyclic strain had less pronounced effects on the retention. These results indicate that collagen synthesis by tenocytes is controlled by a complex mechanosensitive process with a temporal component.

Distributing a fixed amount of cyclic loading to tendon explants over longer periods induces greater cellular and mechanical responses

Tendon overuse injuries are a major source of clinical concern. Cyclic loading causes material damage and induces biochemical responses in tendon. The purpose of this study was to examine the biochemical and biomechanical tendon response after applying cyclical loading over varying durations. Avian flexor digitorum profundus tendons were loaded (3 or 12 MPa) to a fixed number of cycles across either 1 or 12 days in vitro. The tendon response evaluations included biomechanical data gathered during loading and subsequent failure testing. Evaluations also included cellular viability, cell death, and proteoglycan, collagen, collagenase, and prostaglandin E(2) (PGE(2)) content measurements obtained from tissue specimens and media samples. Significant strains (up to 2%) accumulated during loading. Loading to 12 MPa significantly reduced maximum stress (33% and 27%) and energy density (42% and 50%) when applied across 1 or 12 days, respectively. Loading to 3 MPa also caused a 40% reduction in energy density, but only when applied across 12 days. Cell death and collagenase activity increased significantly with increasing magnitude and duration. However, no differences occurred in cell viability or collagen content. Glycosaminoglycan content increased 50% with load magnitude, while PGE(2) production increased 2.5-fold with loading magnitude and 11-fold with increased duration. Mechanical fatigue-induced mechanical property changes were exhibited by the tendons in response to increased loading magnitude across just 1 day. However, when the same loading was applied over a longer period, most outcomes were magnified substantially, relative to the short duration regimens. This is presumably due to the increased response time for the complex cellular response to loading. A key contributor may be the inflammatory mediator, PGE(2), which exhibited large magnitude and duration dependent increases to cyclic loading.