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Wasker SVZ, Challoumas D, Weng W, Murrell GAC, Millar NL. Is neurogenic inflammation involved in tendinopathy? A systematic review. BMJ Open Sport Exerc Med 2023; 9:e001494. [PMID: 36793930 PMCID: PMC9923261 DOI: 10.1136/bmjsem-2022-001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 02/11/2023] Open
Abstract
Neurogenic pain and inflammation have been hypothesised to play an important role in tendinopathy. This systematic review aimed to present and assess the evidence on neurogenic inflammation in tendinopathy. A systematic search was conducted through multiple databases to identify human case-control studies assessing neurogenic inflammation through the upregulation of relevant cells, receptors, markers and mediators. A newly devised tool was used for the methodological quality assessment of studies. Results were pooled based on the cell/receptor/marker/mediator assessed. A total of 31 case-control studies were eligible for inclusion. The tendinopathic tissue was obtained from Achilles (n=11), patellar (n=8), extensor carpi radialis brevis (n=4), rotator cuff (n=4), distal biceps (n=3) and gluteal (n=1) tendons. Through pooling the results of included studies based on the marker of neurogenic inflammation assessed, we identified possible upregulation of protein gene product 9.5 (PGP 9.5), N-methyl-D-aspartate Receptors, glutamate, glutamate receptors (mGLUT), neuropeptide Y (NPY) and adrenoreceptors in tendinopathic tissue versus control. Calcitonin gene-related peptide (CGRP) was not found to be upregulated, and the evidence was conflicting for several other markers. These findings show the involvement of the glutaminergic and sympathetic nervous systems and the upregulation of nerve ingrowth markers supporting the concept that neurogenic inflammation plays a role in tendinopathy.
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Affiliation(s)
- Shimon Vinay Zedeck Wasker
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Dimitris Challoumas
- School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Wai Weng
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - George A C Murrell
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Neal L Millar
- School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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2
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Quintero D, Perucca Orfei C, Kaplan LD, de Girolamo L, Best TM, Kouroupis D. The roles and therapeutic potentialof mesenchymal stem/stromal cells and their extracellular vesicles in tendinopathies. Front Bioeng Biotechnol 2023; 11:1040762. [PMID: 36741745 PMCID: PMC9892947 DOI: 10.3389/fbioe.2023.1040762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023] Open
Abstract
Tendinopathies encompass a highly prevalent, multi-faceted spectrum of disorders, characterized by activity-related pain, compromised function, and propensity for an extended absence from sport and the workplace. The pathophysiology of tendinopathy continues to evolve. For decades, it has been related primarily to repetitive overload trauma but more recently, the onset of tendinopathy has been attributed to the tissue's failed attempt to heal after subclinical inflammatory and immune challenges (failed healing model). Conventional tendinopathy management produces only short-term symptomatic relief and often results in incomplete repair or healing leading to compromised tendon function. For this reason, there has been increased effort to develop therapeutics to overcome the tissue's failed healing response by targeting the cellular metaplasia and pro-inflammatory extra-cellular environment. On this basis, stem cell-based therapies have been proposed as an alternative therapeutic approach designed to modify the course of the various tendon pathologies. Mesenchymal stem/stromal cells (MSCs) are multipotent stem cells often referred to as "medicinal signaling cells" due to their immunomodulatory and anti-inflammatory properties that can produce a pro-regenerative microenvironment in pathological tendons. However, the adoption of MSCs into clinical practice has been limited by FDA regulations and perceived risk of adverse events upon infusion in vivo. The introduction of cell-free approaches, such as the extracellular vesicles of MSCs, has encouraged new perspectives for the treatment of tendinopathies, showing promising short-term results. In this article, we review the most recent advances in MSC-based and MSC-derived therapies for tendinopathies. Preclinical and clinical studies are included with comment on future directions of this rapidly developing therapeutic modality, including the importance of understanding tissue loading and its relationship to any treatment regimen.
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Affiliation(s)
- Daniel Quintero
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Carlotta Perucca Orfei
- Laboratorio di Biotecnologie Applicate all’Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Lee D. Kaplan
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Laura de Girolamo
- Laboratorio di Biotecnologie Applicate all’Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Thomas M. Best
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Dimitrios Kouroupis
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States,Diabetes Research Institute & Cell Transplant Center, Miller School of Medicine, University of Miami, Miami, FL, United States,*Correspondence: Dimitrios Kouroupis,
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3
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Russo V, El Khatib M, Prencipe G, Citeroni MR, Faydaver M, Mauro A, Berardinelli P, Cerveró-Varona A, Haidar-Montes AA, Turriani M, Di Giacinto O, Raspa M, Scavizzi F, Bonaventura F, Stöckl J, Barboni B. Tendon Immune Regeneration: Insights on the Synergetic Role of Stem and Immune Cells during Tendon Regeneration. Cells 2022; 11:cells11030434. [PMID: 35159244 PMCID: PMC8834336 DOI: 10.3390/cells11030434] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 12/11/2022] Open
Abstract
Tendon disorders represent a very common pathology in today’s population, and tendinopathies that account 30% of tendon-related injuries, affect yearly millions of people which in turn cause huge socioeconomic and health repercussions worldwide. Inflammation plays a prominent role in the development of tendon pathologies, and advances in understanding the underlying mechanisms during the inflammatory state have provided additional insights into its potential role in tendon disorders. Different cell compartments, in combination with secreted immune modulators, have shown to control and modulate the inflammatory response during tendinopathies. Stromal compartment represented by tenocytes has shown to display an important role in orchestrating the inflammatory response during tendon injuries due to the interplay they exhibit with the immune-sensing and infiltrating compartments, which belong to resident and recruited immune cells. The use of stem cells or their derived secretomes within the regenerative medicine field might represent synergic new therapeutical approaches that can be used to tune the reaction of immune cells within the damaged tissues. To this end, promising opportunities are headed to the stimulation of macrophages polarization towards anti-inflammatory phenotype together with the recruitment of stem cells, that possess immunomodulatory properties, able to infiltrate within the damaged tissues and improve tendinopathies resolution. Indeed, the comprehension of the interactions between tenocytes or stem cells with the immune cells might considerably modulate the immune reaction solving hence the inflammatory response and preventing fibrotic tissue formation. The purpose of this review is to compare the roles of distinct cell compartments during tendon homeostasis and injury. Furthermore, the role of immune cells in this field, as well as their interactions with stem cells and tenocytes during tendon regeneration, will be discussed to gain insights into new ways for dealing with tendinopathies.
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Affiliation(s)
- Valentina Russo
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Mohammad El Khatib
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Giuseppe Prencipe
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
- Correspondence:
| | - Maria Rita Citeroni
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Melisa Faydaver
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Annunziata Mauro
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Paolo Berardinelli
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Adrián Cerveró-Varona
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Arlette A. Haidar-Montes
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Maura Turriani
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Oriana Di Giacinto
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
| | - Marcello Raspa
- National Research Council (CNR), Campus International Development (EMMA-INFRAFRONTIER-IMPC), Institute of Biochemistry and Cellular Biology (IBBC), 00015 Monterotondo Scalo, Italy; (M.R.); (F.S.); (F.B.)
| | - Ferdinando Scavizzi
- National Research Council (CNR), Campus International Development (EMMA-INFRAFRONTIER-IMPC), Institute of Biochemistry and Cellular Biology (IBBC), 00015 Monterotondo Scalo, Italy; (M.R.); (F.S.); (F.B.)
| | - Fabrizio Bonaventura
- National Research Council (CNR), Campus International Development (EMMA-INFRAFRONTIER-IMPC), Institute of Biochemistry and Cellular Biology (IBBC), 00015 Monterotondo Scalo, Italy; (M.R.); (F.S.); (F.B.)
| | - Johannes Stöckl
- Centre for Pathophysiology, Infectiology and Immunology, Institute of Immunology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Barbara Barboni
- Unit of Basic and Applied Sciences, Faculty of Biosciences and Agro-Food and Environmental Technologies, University of Teramo, 64100 Teramo, Italy; (V.R.); (M.E.K.); (M.R.C.); (M.F.); (A.M.); (P.B.); (A.C.-V.); (A.A.H.-M.); (M.T.); (O.D.G.); (B.B.)
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4
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The Effect of Age and Intrinsic Aerobic Exercise Capacity on the Expression of Inflammation and Remodeling Markers in Rat Achilles Tendons. Int J Mol Sci 2021; 23:ijms23010079. [PMID: 35008516 PMCID: PMC8744822 DOI: 10.3390/ijms23010079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/19/2022] Open
Abstract
Old age, adiposity, and metabolic disorders are known as risk factors for chronic tendinopathy, which is a common problem in both athletes and the general population. However, the importance of these influencing factors has not yet been well understood. This study investigated alterations in gene expression and histology of Achilles tendons of young (10 weeks) and old (100 weeks) rats bred for low (low capacity runners, LCR) and high (high capacity runners, HCR) intrinsic aerobic exercise capacity. In this rat model, LCR displayed a phenotype of reduced exercise capacity, higher body weight, and metabolic dysfunctions compared to HCR. We hypothesized that the risk factors for tendinopathy in old LCR could lead to more pronounced impairments in Achilles tendon tissue. In quantitative real-time PCR (qPCR), age-related downregulation of tenocyte markers e.g., tenomodulin, genes related to matrix modeling and remodeling (e.g., collagens, elastin, biglycan, fibronectin, tenascin C) as well as transforming growth factor beta 3 (Tgfb3) have been detected. Inflammation marker cyclooxygenase 2 (Cox2) was downregulated in old rats, while microsomal prostaglandin E synthase 2 (Ptges2) was upregulated in old HCR and old LCR. In all groups, interleukin 6 (Il6), interleukin 1 beta (Il1b), and tumor necrosis factor alpha (Tnfa) showed no significant alteration. In histological evaluation, tendons of old rats had fewer and more elongated tenocyte nuclei than young rats. Even though a higher content of glycosaminoglycans, a sign of degeneration, was found in old HCR and LCR, no further signs of tendinopathy were detectable in tendons of old rats by histological evaluation. Low intrinsic aerobic exercise capacity and the associated phenotype did not show significant effects on gene expression and tendon histology. These findings indicate that aging seems to play a prominent role in molecular and structural alterations of Achilles tendon tissue and suggests that other risk factors associated with intrinsic aerobic exercise capacity are less influential in this rat model.
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5
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Perucca Orfei C, Bowles AC, Kouroupis D, Willman MA, Ragni E, Kaplan LD, Best TM, Correa D, de Girolamo L. Human Tendon Stem/Progenitor Cell Features and Functionality Are Highly Influenced by in vitro Culture Conditions. Front Bioeng Biotechnol 2021; 9:711964. [PMID: 34616717 PMCID: PMC8488466 DOI: 10.3389/fbioe.2021.711964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 01/09/2023] Open
Abstract
Our understanding of tendon biology continues to evolve, thus leading to opportunities for developing novel, evidence-based effective therapies for the treatment of tendon disorders. Implementing the knowledge of tendon stem/progenitor cells (TSPCs) and assessing their potential in enhancing tendon repair could fill an important gap in this regard. We described different molecular and phenotypic profiles of TSPCs modulated by culture density, as well as their multipotency and secretory activities. Moreover, in the same experimental setting, we evaluated for different responses to inflammatory stimuli mediated by TNFα and IFNγ. We also preliminarily investigated their immunomodulatory activity and their role in regulating degradation of substance P. Our findings indicated that TSPCs cultured at low density (LD) exhibited cobblestone morphology and a reduced propensity to differentiate. A distinctive immunophenotypic profile was also observed with high secretory and promising immunomodulatory responses when primed with TNFα and IFNγ. In contrast, TSPCs cultured at high density (HD) showed a more elongated fibroblast-like morphology, a greater adipogenic differentiation potential, and a higher expression of tendon-related genes with respect to LD. Finally, HD TSPCs showed immunomodulatory potential when primed with TNFα and IFNγ, which was slightly lower than that shown by LD. A shift from low to high culture density during TSPC expansion demonstrated intermediate features confirming the cellular adaptability of TSPCs. Taken together, these experiments allowed us to identify relevant differences in TSPCs based on culture conditions. This ability of TSPCs to acquire distinguished morphology, phenotype, gene expression profile, and functional response advances our current understanding of tendons at a cellular level and suggests responsivity to cues in their in situ microenvironment.
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Affiliation(s)
- Carlotta Perucca Orfei
- Laboratorio di Biotecnologie Applicate all'Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Annie C Bowles
- Department of Orthopedics, UHealth Sports Medicine Institute, University of Miami, Miller School of Medicine, Miami, FL, United States.,Diabetes Research Institute and Cell Transplantation Center, University of Miami, Miller School of Medicine, Miami, FL, United States.,Department of Biomedical Engineering College of Engineering, University of Miami, Miami, FL, United States
| | - Dimitrios Kouroupis
- Department of Orthopedics, UHealth Sports Medicine Institute, University of Miami, Miller School of Medicine, Miami, FL, United States.,Diabetes Research Institute and Cell Transplantation Center, University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Melissa A Willman
- Diabetes Research Institute and Cell Transplantation Center, University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Enrico Ragni
- Laboratorio di Biotecnologie Applicate all'Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Lee D Kaplan
- Department of Orthopedics, UHealth Sports Medicine Institute, University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Thomas M Best
- Department of Orthopedics, UHealth Sports Medicine Institute, University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Diego Correa
- Department of Orthopedics, UHealth Sports Medicine Institute, University of Miami, Miller School of Medicine, Miami, FL, United States.,Diabetes Research Institute and Cell Transplantation Center, University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Laura de Girolamo
- Laboratorio di Biotecnologie Applicate all'Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Savva C, Karagiannis C, Korakakis V, Efstathiou M. The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review. J Man Manip Ther 2021; 29:276-287. [PMID: 33769226 PMCID: PMC8491707 DOI: 10.1080/10669817.2021.1904348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.
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Affiliation(s)
- Christos Savva
- Department of Health Science, European University, Nicosia, Cyprus
| | | | | | - Michalis Efstathiou
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
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7
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Glutamate triggers the expression of functional ionotropic and metabotropic glutamate receptors in mast cells. Cell Mol Immunol 2021; 18:2383-2392. [PMID: 32313211 PMCID: PMC8484602 DOI: 10.1038/s41423-020-0421-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/16/2020] [Indexed: 02/07/2023] Open
Abstract
Mast cells are emerging as players in the communication between peripheral nerve endings and cells of the immune system. However, it is not clear the mechanism by which mast cells communicate with peripheral nerves. We previously found that mast cells located within healing tendons can express glutamate receptors, raising the possibility that mast cells may be sensitive to glutamate signaling. To evaluate this hypothesis, we stimulated primary mast cells with glutamate and showed that glutamate induced the profound upregulation of a panel of glutamate receptors of both the ionotropic type (NMDAR1, NMDAR2A, and NMDAR2B) and the metabotropic type (mGluR2 and mGluR7) at both the mRNA and protein levels. The binding of glutamate to glutamate receptors on the mast cell surface was confirmed. Further, glutamate had extensive effects on gene expression in the mast cells, including the upregulation of pro-inflammatory components such as IL-6 and CCL2. Glutamate also induced the upregulation of transcription factors, including Egr2, Egr3 and, in particular, FosB. The extensive induction of FosB was confirmed by immunofluorescence assessment. Glutamate receptor antagonists abrogated the responses of the mast cells to glutamate, supporting the supposition of a functional glutamate-glutamate receptor axis in mast cells. Finally, we provide in vivo evidence supporting a functional glutamate-glutamate receptor axis in the mast cells of injured tendons. Together, these findings establish glutamate as an effector of mast cell function, thereby introducing a novel principle for how cells in the immune system can communicate with nerve cells.
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8
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Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD, Murrell GAC, McInnes IB, Rodeo SA. Tendinopathy. Nat Rev Dis Primers 2021; 7:1. [PMID: 33414454 DOI: 10.1038/s41572-020-00234-1] [Citation(s) in RCA: 283] [Impact Index Per Article: 94.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/14/2022]
Abstract
Tendinopathy describes a complex multifaceted pathology of the tendon, characterized by pain, decline in function and reduced exercise tolerance. The most common overuse tendinopathies involve the rotator cuff tendon, medial and lateral elbow epicondyles, patellar tendon, gluteal tendons and the Achilles tendon. The prominent histological and molecular features of tendinopathy include disorganization of collagen fibres, an increase in the microvasculature and sensory nerve innervation, dysregulated extracellular matrix homeostasis, increased immune cells and inflammatory mediators, and enhanced cellular apoptosis. Although diagnosis is mostly achieved based on clinical symptoms, in some cases, additional pain-provoking tests and imaging might be necessary. Management consists of different exercise and loading programmes, therapeutic modalities and surgical interventions; however, their effectiveness remains ambiguous. Future research should focus on elucidating the key functional pathways implicated in clinical disease and on improved rehabilitation protocols.
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Affiliation(s)
- Neal L Millar
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK.
| | | | - Kristian Thorborg
- Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Paul D Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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9
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El-Habta R, Chen J, Pingel J, Backman LJ. Tendinosis-like changes in denervated rat Achilles tendon. BMC Musculoskelet Disord 2018; 19:426. [PMID: 30497469 PMCID: PMC6267070 DOI: 10.1186/s12891-018-2353-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 11/20/2018] [Indexed: 01/02/2023] Open
Abstract
Background Tendon disorders are common and lead to significant disability and pain. Our knowledge of the ‘tennis elbow’, the ‘jumpers knee’, and Achilles tendinosis has increased over the years, but changes in denervated tendons is yet to be described in detail. The aim of the present study was to investigate the morphological and biochemical changes in tendon tissue following two weeks of denervation using a unilateral sciatic nerve transection model in rat Achilles tendons. Methods Tendons were compared with respect to cell number, nuclear roundness, and fiber structure. The non-denervated contralateral tendon served as a control. Also, the expression of neuromodulators such as substance P and its preferred receptor neurokinin-1 receptor, NK-1R, was evaluated using real-time qRT-PCR. Results Our results showed that denervated tendons expressed morphological changes such as hypercellularity; disfigured cells; disorganization of the collagen network; increased production of type III collagen; and increased expression of NK-1R. Conclusion Taken together these data provide new insights into the histopathology of denervated tendons showing that denervation causes somewhat similar changes in the Achilles tendon as does tendinosis in rats.
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Affiliation(s)
- Roine El-Habta
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Johan Bures väg 12, 901 87, Umeå, Sweden.
| | - Jialin Chen
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Johan Bures väg 12, 901 87, Umeå, Sweden
| | - Jessica Pingel
- Department of Neuroscience, University of Copenhagen, København, Denmark
| | - Ludvig J Backman
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Johan Bures väg 12, 901 87, Umeå, Sweden.,Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
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10
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Beccati F, Pepe M, Antinori L, Pascucci L, Chiaradia E, Mandara MT. Sympathetic Innervation and Adrenergic Receptors in Equine Deep Digital Flexor Tendinopathy: Preliminary Results. J Comp Pathol 2018; 163:33-37. [PMID: 30213372 DOI: 10.1016/j.jcpa.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 12/01/2022]
Abstract
The aim of this study was to delineate the pattern of sympathetic innervation in the suprasesamoidean region of the deep digital flexor tendon (DDFT) in horses with tendinopathy by immunohistochemical labelling for tyrosine hydroxylase (TH) and α-1 adrenergic receptor (α1-AR). Twelve forelimbs were obtained from 10 horses with DDFT tendinopathy and six feet obtained from six horses were used as healthy controls. Post-mortem radiographic, ultrasonographic and gross examinations were performed on the suprasesamoidean area of the DDFT to assess the presence of tendinopathy. Longitudinal sections were collected and processed. Lesions were classified as core lesions, dorsal border lesions and parasagittal oblique splits. Immunohistochemistry was performed and the degree of immunoreaction was classified as absent, mild or marked. Seven core lesions, four dorsal border lesions and one parasagittal oblique split were identified. There was no increased expression of sympathetic innervation in samples with a dorsal border lesion of the DDFT compared with healthy samples. In contrast, core lesions showed increased expression of α1-AR and reduced expression of TH, which supports the hypothesis of a compensatory imbalance between the sympathetic mediator and the sympathetic receptors as a cause or effect of structural damage. In addition, adrenergic activation could stimulate cell proliferation and differentiation within these lesions.
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Affiliation(s)
- F Beccati
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy.
| | - M Pepe
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
| | - L Antinori
- Clinica Veterinaria Roma Sud, Via Pilade Mazza, 24, Roma, Italy
| | - L Pascucci
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
| | - E Chiaradia
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
| | - M T Mandara
- Sport Horses Studies Centre, Department of Veterinary Medicine, University of Perugia, Via San Costanzo 4, Perugia, Italy
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11
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Tuzmen C, Verdelis K, Weiss L, Campbell P. Crosstalk between substance P and calcitonin gene-related peptide during heterotopic ossification in murine Achilles tendon. J Orthop Res 2018; 36:1444-1455. [PMID: 29227562 PMCID: PMC6449576 DOI: 10.1002/jor.23833] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 12/04/2017] [Indexed: 02/04/2023]
Abstract
Heterotopic ossification (HO) is abnormal bone formation within soft tissue, usually predisposed by neurogenic or musculoskeletal trauma. Inflammation resulting from trauma is considered to be the main trigger for HO by eliciting changes within the injury site, including elevation of bone morphogenetic proteins (BMPs). Recent research, however, has also associated changes in sensory neuropeptide expression with HO. Substance P (SP) and calcitonin gene-related peptide (CGRP) are two of those neuropeptides that have been implicated with various aspects of HO, including regulation of inflammation and BMP signaling. Despite discoveries associating SP and CGRP with soft tissue HO, it remains unclear whether SP and CGRP have a direct role in the induction of HO. Here, we investigated the effect of SP and CGRP in vivo with the aid of inkjet-based biopatterning technology to controllably deliver these neuropeptides onto a murine Achilles tendon. While we did not observe any significant effect with CGRP, SP alone promoted HO in vivo with increased expression of BMP2. Remarkably, when SP and CGRP were delivered together, CGRP counteracted the effect of SP and essentially blocked SP-induced HO. This report contributes to the understanding of the complex problem of HO pathophysiology and warrants more study to better elucidate the interplay between SP and CGRP in the induction of HO. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1444-1455, 2018.
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Affiliation(s)
- Ceren Tuzmen
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Kostas Verdelis
- Center for Craniofacial Regeneration, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lee Weiss
- Robotics Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Phil Campbell
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania,McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Engineering Research Accelerator, Carnegie Mellon University, Pittsburgh, Pennsylvania
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12
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Tang C, Chen Y, Huang J, Zhao K, Chen X, Yin Z, Heng BC, Chen W, Shen W. The roles of inflammatory mediators and immunocytes in tendinopathy. J Orthop Translat 2018; 14:23-33. [PMID: 30035030 PMCID: PMC6034108 DOI: 10.1016/j.jot.2018.03.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/13/2018] [Accepted: 03/19/2018] [Indexed: 02/06/2023] Open
Abstract
Tendinopathy is a common disease of the musculoskeletal system, particularly in athletes and sports amateurs. In this review, we will present evidence for the critical role of inflammatory mediators and immunocytes in the pathogenesis of tendinopathy and the efficacy of current antiinflammatory therapy and regenerative medicine in the clinic. We hereby propose a hypothesis that in addition to pulling force there may be compressive forces being exerted on the tendon during physical activities, which may initiate the onset of tendinopathy. We performed literature searches on MEDLINE from the inception of this review to February 2018. No language restrictions were imposed. The search terms were as follows: ("Tendinopathy"[Mesh] OR "Tendon Injuries"[Mesh] OR "Tendinitis"[Mesh] OR "Tendon"[Mesh]) AND (Inflammation OR "Inflammatory mediator*" OR Immunocyte*) OR ("anti inflammatory*" OR "regenerative medicine"). Inclusion criteria included articles that were original and reliable, with the main contents being highly relevant to our review. Exclusion criteria included articles that were not available online or have not been published. We scanned the abstract of these articles first. This was then followed by a careful screening of the articles which might be suitable for our review. Finally, 84 articles were selected as references. This review article is written in the narrative form. The translational potential of this article: Understanding the mechanisms of inflammation and existing antiinflammatory and regenerative therapies is key to the development of therapeutic strategies in tendinopathy.
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Affiliation(s)
- Chenqi Tang
- Department of Orthopedic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang 310009, China.,Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Zhejiang 310000, China.,Orthopaedics Research Institute, Zhejiang Univerisity, Zhejiang 310000, China.,Department of Sports Medicine, School of Medicine, Zhejiang University, Zhejiang 310000, China.,China Orthopaedic Regenerative Medicine (CORMed), Chinese Medical Association, Hangzhou, China
| | - Yangwu Chen
- Department of Orthopedic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang 310009, China.,Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Zhejiang 310000, China.,Orthopaedics Research Institute, Zhejiang Univerisity, Zhejiang 310000, China.,Department of Sports Medicine, School of Medicine, Zhejiang University, Zhejiang 310000, China.,China Orthopaedic Regenerative Medicine (CORMed), Chinese Medical Association, Hangzhou, China
| | - Jiayun Huang
- Department of Orthopedic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang 310009, China.,Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Zhejiang 310000, China.,Orthopaedics Research Institute, Zhejiang Univerisity, Zhejiang 310000, China.,Department of Sports Medicine, School of Medicine, Zhejiang University, Zhejiang 310000, China.,China Orthopaedic Regenerative Medicine (CORMed), Chinese Medical Association, Hangzhou, China
| | - Kun Zhao
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Zhejiang 310000, China.,Department of Sports Medicine, School of Medicine, Zhejiang University, Zhejiang 310000, China.,China Orthopaedic Regenerative Medicine (CORMed), Chinese Medical Association, Hangzhou, China
| | - Xiao Chen
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Zhejiang 310000, China.,Department of Sports Medicine, School of Medicine, Zhejiang University, Zhejiang 310000, China.,China Orthopaedic Regenerative Medicine (CORMed), Chinese Medical Association, Hangzhou, China
| | - Zi Yin
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Zhejiang 310000, China.,Department of Sports Medicine, School of Medicine, Zhejiang University, Zhejiang 310000, China
| | - Boon Chin Heng
- Faculty of Dentistry, Department of Endodontology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Weishan Chen
- Department of Orthopedic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang 310009, China.,Orthopaedics Research Institute, Zhejiang Univerisity, Zhejiang 310000, China
| | - Weiliang Shen
- Department of Orthopedic Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang 310009, China.,Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Zhejiang 310000, China.,Orthopaedics Research Institute, Zhejiang Univerisity, Zhejiang 310000, China.,Department of Sports Medicine, School of Medicine, Zhejiang University, Zhejiang 310000, China.,China Orthopaedic Regenerative Medicine (CORMed), Chinese Medical Association, Hangzhou, China
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13
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Fouda MB, Thankam FG, Dilisio MF, Agrawal DK. Alterations in tendon microenvironment in response to mechanical load: potential molecular targets for treatment strategies. Am J Transl Res 2017; 9:4341-4360. [PMID: 29118899 PMCID: PMC5666046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
Rotator cuff (RC) tendons could beinflicted in many ways with an eventual outcome of pain, weakness and disability, which represent a large burden on health care cost. However, optimal healing, either conservatively or with surgical intervention, remains an issue that needs further investigation. Disorders of the RC tendons may result from external factors like trauma, or internal factors through physiologic and metabolic derangement. Most RC tendon disorders may be asymptomatic and may result from an over-activity of the inflicted shoulder and its tendons. Such tendon disorders are poorly diagnosed since patients do not seek medical attention until pain or weakness ensue. Immunological and biochemical events in RC disorders due to mechanical intolerance have not been investigated. Generally, the mechanical load drives normal physiological properties of the tendon. But, mechanical overload/burden exerts stress on tenocytes, and disrupts the tendon microenvironment by triggering a multitude of signaling pathways leading to extracellular matrix remodeling, disorganization, alteration in collagen composition and apoptosis. These events result in weak tendon which is highly susceptible to rupture or tear. In this article, we critically reviewed the intrinsic signaling pathways that are excessively triggered by continuous mechanical load and the counteracting physiological responses and associated derangements. The elucidation of the molecular events underlying mechanical stress-induced symptomatic/asymptomatic tendinopathy could provide information on potential target sites for translational application in the management of rotator cuff disorders.
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Affiliation(s)
- Mohamed B Fouda
- Department of Clinical & Translational Science, Creighton University School of MedicineOmaha 68178, NE, USA
| | - Finosh G Thankam
- Department of Clinical & Translational Science, Creighton University School of MedicineOmaha 68178, NE, USA
| | - Matthew F Dilisio
- Department of Clinical & Translational Science, Creighton University School of MedicineOmaha 68178, NE, USA
- Department of Orthopedic Surgery, Creighton University School of MedicineOmaha 68178, NE, USA
| | - Devendra K Agrawal
- Department of Clinical & Translational Science, Creighton University School of MedicineOmaha 68178, NE, USA
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O’Neill S, Watson PJ, Barry S. WHY ARE ECCENTRIC EXERCISES EFFECTIVE FOR ACHILLES TENDINOPATHY? Int J Sports Phys Ther 2015; 10:552-62. [PMID: 26347394 PMCID: PMC4527202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
UNLABELLED Achilles Tendinopathy is a complex problem, with the most common conservative treatment being eccentric exercises. Despite multiple studies assessing this treatment regime little is known about the mechanism of effect. This lack of understanding may be hindering therapeutic care and preventing optimal rehabilitation. Of the mechanisms proposed, most relate to tendon adaptation and fail to consider other possibilities. The current consensus is that tendon adaptation does not occur within timeframes associated with clinical improvements, therefore the clinical benefits must occur through another unidentified pathway. This clinical commentary critically reviews each of the proposed theories and highlights that muscle alterations are observed prior to onset of Achilles Tendinopathy and during the disease. Evidence shows that the observed muscle alterations change with treatment and that these adaptations have the ability to reduce tendon load and thereby improve tendon health. The purpose of this clinical commentary is to review previous theories regarding the mechanisms by which eccentric exercise might affect Achilles tendinopathy and offers a novel mechanism by which the plantarflexor muscles may shield the Achilles tendon. LEVEL OF EVIDENCE 5.
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Beccati F, Pepe M, Pascucci L, Ceccarelli P, Chiaradia E, Mancini F, Mandara MT. Sympathetic innervation of the suprasesamoidean region of the deep digital flexor tendon in the forelimbs of horses. Vet J 2015; 205:413-6. [PMID: 26095033 DOI: 10.1016/j.tvjl.2015.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/03/2015] [Accepted: 06/04/2015] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to delineate the pattern of sympathetic innervation in the suprasesamoidean region of the deep digital flexor tendon (DDFT) in horses using immunohistochemical staining (IHC) for tyrosine hydroxylase (TH) and alpha-1 adrenergic receptor (α1-AR). Fourteen forelimbs were collected from 10 horses. Longitudinal sections of the suprasesamoidean region of healthy DDFTs were harvested. Most of the sympathetic innervation was found to be in the walls of blood vessels. The tendon tissue proper was sparsely innervated, with a lesser degree of innervation within the dorsal fibrocartilage. Increased α1-AR immunostaining was also detected in walls of blood vessels and in spindle cells of fibrocartilage. Both α1-AR and TH immunostaining were detected in tenocytes. These findings support the presence of autocrine/paracrine catecholaminergic signalling in equine tendon tissue.
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Affiliation(s)
- F Beccati
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy.
| | - M Pepe
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - L Pascucci
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - P Ceccarelli
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - E Chiaradia
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - F Mancini
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
| | - M T Mandara
- Centro di Studi del Cavallo Sportivo, Dipartimento di Medicina Veterinaria, Università degli Studi di Perugia, Via San Costanzo 4, 06126 Perugia, Italy
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16
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Ellenbecker TS, Nirschl R, Renstrom P. Current concepts in examination and treatment of elbow tendon injury. Sports Health 2014; 5:186-94. [PMID: 24427389 PMCID: PMC3658379 DOI: 10.1177/1941738112464761] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Context: Injuries to the tendons of the elbow occur frequently in the overhead athlete, creating a significant loss of function and dilemma to sports medicine professionals. A detailed review of the anatomy, etiology, and pathophysiology of tendon injury coupled with comprehensive evaluation and treatment information is needed for clinicians to optimally design treatment programs for rehabilitation and prevention. Evidence Acquisitions: The PubMed database was searched in January 2012 for English-language articles pertaining to elbow tendon injury. Results: Detailed information on tendon pathophysiology was found along with incidence of elbow injury in overhead athletes. Several evidence-based reviews were identified, providing a thorough review of the recommended rehabilitation for elbow tendon injury. Conclusions: Humeral epicondylitis is an extra-articular tendon injury that is common in athletes subjected to repetitive upper extremity loading. Research is limited on the identification of treatment modalities that can reduce pain and restore function to the elbow. Eccentric exercise has been studied in several investigations and, when coupled with a complete upper extremity strengthening program, can produce positive results in patients with elbow tendon injury. Further research is needed in high-level study to delineate optimal treatment methods.
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Affiliation(s)
| | - Robert Nirschl
- Nirschl Orthopaedic Center for Sports Medicine and Joint Reconstruction, Arlington, Virginia
| | - Per Renstrom
- Centre for Sports Trauma Research, Karolinska Institute, Stockholm, Sweden
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17
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Lui PPY. Histopathological changes in tendinopathy--potential roles of BMPs? Rheumatology (Oxford) 2013; 52:2116-2126. [DOI: 10.1093/rheumatology/ket165] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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18
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Pingel J, Wienecke J, Kongsgaard M, Behzad H, Abraham T, Langberg H, Scott A. Increased mast cell numbers in a calcaneal tendon overuse model. Scand J Med Sci Sports 2013; 23:e353-60. [PMID: 23889295 PMCID: PMC4282450 DOI: 10.1111/sms.12089] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2013] [Indexed: 02/06/2023]
Abstract
Tendinopathy is often discovered late because the initial development of tendon pathology is asymptomatic. The aim of this study was to examine the potential role of mast cell involvement in early tendinopathy using a high-intensity uphill running (HIUR) exercise model. Twenty-four male Wistar rats were divided in two groups: running group (n = 12); sedentary control group (n = 12). The running-group was exposed to the HIUR exercise protocol for 7 weeks. The calcaneal tendons of both hind limbs were dissected. The right tendon was used for histologic analysis using Bonar score, immunohistochemistry, and second harmonic generation microscopy (SHGM). The left tendon was used for quantitative polymerase chain reaction (qPCR) analysis. An increased tendon cell density in the runners were observed compared to the controls (P = 0.05). Further, the intensity of immunostaining of protein kinase B, P = 0.03; 2.75 ± 0.54 vs 1.17 ± 0.53, was increased in the runners. The Bonar score (P = 0.05), and the number of mast cells (P = 0.02) were significantly higher in the runners compared to the controls. Furthermore, SHGM showed focal collagen disorganization in the runners, and reduced collagen density (P = 0.03). IL-3 mRNA levels were correlated with mast cell number in sedentary animals. The qPCR analysis showed no significant differences between the groups in the other analyzed targets. The current study demonstrates that 7-week HIUR causes structural changes in the calcaneal tendon, and further that these changes are associated with an increased mast cell density.
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Affiliation(s)
- J Pingel
- Institute of Sports Medicine, Department of Orthopaedic Surgery M. Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Fabbro E, Ferrero G, Orlandi D, Martini C, Nosenzo F, Serafini G, Silvestri E, Sconfienza LM. Rotator cuff ultrasound-guided procedures: technical and outcome improvements. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/iim.12.57] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
CONTEXT Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited. EVIDENCE ACQUISITION The authors conducted a MEDLINE search on tendinopathy, or "tendonitis" or "tendinosis" or "epicondylitis" or "jumpers knee" from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature. RESULTS Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies. CONCLUSIONS Novel targeted therapies are emerging, but multicenter trials are needed to confirm the results of exercise and mini-invasive treatments.
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Affiliation(s)
- Paul W Ackermann
- Section of Orthopedics and Sports Medicine, Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden
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Lui PPY, Maffulli N, Rolf C, Smith RKW. What are the validated animal models for tendinopathy? Scand J Med Sci Sports 2011; 21:3-17. [PMID: 20673247 DOI: 10.1111/j.1600-0838.2010.01164.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- P P Y Lui
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Sharma A, Abraham T, Sampaio A, Cowan M, Underhill M, Scott A. Sodium cromolyn reduces expression of CTGF, ADAMTS1, and TIMP3 and modulates post-injury patellar tendon morphology. J Orthop Res 2011; 29:678-83. [PMID: 21437947 PMCID: PMC3951484 DOI: 10.1002/jor.21291] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 10/04/2010] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to determine whether administration of a mast cell inhibitor (sodium cromolyn, SC) would influence tendon repair and extracellular matrix gene expression following acute injury. CD1 mouse patellar tendons were unilaterally injured and mast cell prevalence was determined. The effect of SC injection on tendon hypercellularity, cross-sectional area, collagen organization, and expression of extracellular matrix-related genes was examined. Mast cell prevalence was markedly increased in injured patellar tendons (p = 0.009), especially at 8 weeks post-injury (p = 0.025). SC injection increased collagen organization compared to uninjected animals at 4 weeks and attenuated the development of tendon hypercellularity and tendon thickening post-injury. Expression of CTGF, ADAMTS1, and TIMP3 in injured tendon was reduced in the SC group. SC injections moderated the structural alterations of healing tendon in association with downregulation of several genes associated with tendon fibrosis. This work corroborates previous findings pointing to a role of mast cells in tendon repair.
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Affiliation(s)
- Aishwariya Sharma
- Department of Cellular and Physiological Sciences, University of British Columbia
| | - Thomas Abraham
- James Hogg Centre for Cardiovascular Research, St Paul’s Hospital
| | - Arthur Sampaio
- Department of Cellular and Physiological Sciences, University of British Columbia
| | - Matthew Cowan
- Biomedical Research Centre, University of British Columbia
| | - Michael Underhill
- Department of Cellular and Physiological Sciences, University of British Columbia
| | - Alex Scott
- Department of Physical Therapy, University of British Columbia,Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute,Correspondence or reprint requests should be addressed to A Scott, Department of Physical Therapy, University of British Columbia, 212 - 2177 Wesbrook Mall, Vancouver, BC V6T 1Z3,
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24
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Andia I, Sanchez M, Maffulli N. Tendon healing and platelet-rich plasma therapies. Expert Opin Biol Ther 2010; 10:1415-26. [DOI: 10.1517/14712598.2010.514603] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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