The Role of Muscle Loading on Bone (Re)modeling at the Developing Enthesis

Muscle forces are necessary for the development and maintenance of a mineralized skeleton. Removal of loads leads to malformed bones and impaired musculoskeletal function due to changes in bone (re)modeling. In the current study, the development of a mineralized junction at the interface between muscle and bone was examined under normal and impaired loading conditions. Unilateral mouse rotator cuff muscles were paralyzed using botulinum toxin A at birth. Control groups consisted of contralateral shoulders injected with saline and a separate group of normal mice. It was hypothesized that muscle unloading would suppress bone formation and enhance bone resorption at the enthesis, and that the unloading-induced bony defects could be rescued by suppressing osteoclast activity. In order to modulate osteoclast activity, mice were injected with the bisphosphonate alendronate. Bone formation was measured at the tendon enthesis using alizarin and calcein fluorescent labeling of bone surfaces followed by quantitative histomorphometry of histologic sections. Bone volume and architecture was measured using micro computed tomography. Osteoclast surface was determined via quantitative histomorphometry of tartrate resistant acid phosphatase stained histologic sections. Muscle unloading resulted in delayed initiation of endochondral ossification at the enthesis, but did not impair bone formation rate. Unloading led to severe defects in bone volume and trabecular bone architecture. These defects were partially rescued by suppression of osteoclast activity through alendronate treatment, and the effect of alendronate was dose dependent. Similarly, bone formation rate was increased with increasing alendronate dose across loading groups. The bony defects caused by unloading were therefore likely due to maintained high osteoclast activity, which normally decreases from neonatal through mature timepoints. These results have important implications for the treatment of muscle unloading conditions such as neonatal brachial plexus palsy, which results in shoulder paralysis at birth and subsequent defects in the rotator cuff enthesis and humeral head.     

A Canine Non-Weight-Bearing Model with Radial Neurectomy for Rotator Cuff Repair

Background

The major concern of using a large animal model to study rotator cuff repair is the high rate of repair retears. The purpose of this study was to test a non-weight-bearing (NWB) canine model for rotator cuff repair research.

Methods

First, in the in vitro study, 18 shoulders were randomized to 3 groups. 1) Full-width transections repaired with modified Mason-Allen sutures using 3-0 polyglactin suture, 2) Group 1 repaired using number 2 (#2) polyester braid and long-chain polyethylene suture, and 3) Partial-width transections leaving the superior 2 mm infraspinatus tendon intact without repair. In the in vivo study of 6 dogs, the infraspinatus tendon was partially transected as the same as the in vitro group 3. A radial neurectomy was performed to prevent weight bearing. The operated limb was slung in a custom-made jacket for 6 weeks.

Results

In the in vitro study, mean ultimate tensile load and stiffness in Group 2 were significantly higher than Group 1 and 3 (p<0.05). In the in vivo study, gross inspection and histology showed that the preserved superior 2-mm portion of the infraspinatus tendon remained intact with normal structure.

Conclusions

Based on the biomechanical and histological findings, this canine NWB model may be an appropriate and useful model for studies of rotator cuff repair.     

On the suitability of using surface electrode placements to estimate muscle activity of the rotator cuff as recorded by intramuscular electrodes

BackgroundElectromyography (EMG) is commonly used to assess muscle activity. Although previous studies have had moderate success in predicting individual intramuscular muscle activity from surface electrodes, extensive data does not exist for the rotator cuff. This study aimed to determine how reliably surface electrodes represent rotator cuff activity during 20 maximal exertions.MethodsFive channels of EMG were recorded on the following rotator cuff muscles: supraspinatus and infraspinatus intramuscular and surface recordings, and teres minor intramuscular recordings. An additional 3 surface electrodes were placed over the upper and middle trapezius and posterior deltoid. Subjects performed ramped maximal voluntary contractions (MVCs) for each muscle, followed by 20 isometric maximal exertions. Linear least squares best fit regressions (unconstrained and constrained with zero-intercept) were used to compare: intramuscular and surface supraspinatus and infraspinatus signals, respectively, and intramuscular teres minor and surface infraspinatus signals.FindingsRelationships existed between wire and surface electrode measurements for all rotator cuff muscles: supraspinatus (r² = 0.73); teres minor (r² = 0.61); infraspinatus (r² = 0.40), however prediction equations indicated large overestimations and offsets.InterpretationWhen appropriate multiplicative coefficients are considered, surface supraspinatus and infraspinatus electrodes may be used to estimate intramuscular supraspinatus and teres minor activations, respectively, in maximal exertions similar to those tested. However, until these relationships are better defined in other postures, intensities and exertion types, the use of surface electrodes to estimate indwelling rotator cuff activity is cautioned against.     

Scapular orientation following repetitive prone rowing: Implications for potential subacromial impingement mechanisms

While fatigue of the rotator cuff demonstrably causes superior humeral head migration and concomitant risk of impingement, the relationship between specific muscular fatigue, scapular dyskinesis and impingement risk is less clear. The purpose of this study was to examine changes in scapular orientation following a simulated prone rowing fatiguing protocol that targeted the scapula stabilizing muscles while attempting to alleviate rotator cuff muscular demands. Scapular orientation and muscle activity were collected from participants before and immediately after the fatiguing task. This task fatigued both the stabilizing (upper and middle trapezius, and latissimus dorsi) and rotator cuff (supraspinatus, and infraspinatus) muscles. The upper extremity muscle fatigue pattern caused by the protocol did not elicit any significantly changes in three-dimensional scapular position with all post-fatigue changes being ?1° (p = 0.17–0.58). These results indicated that scapular reorientation is likely not the dominant mechanism of fatigue-induced subacromial impingement development. However, the substantial variability present in the kinematics prevents complete exclusion of scapular dyskinesis as a secondary causal mechanism of impingement.     

The effect of altered loading following rotator cuff tears in a rat model on the regional mechanical properties of the long head of the biceps tendon

Biceps tendon pathology is a common clinical problem often seen in conjunction with rotator cuff tears. A previous study found detrimental changes to biceps tendons in the presence of rotator cuff tears in a rat model. Therefore, the objective of this study was to utilize this model along with models of altered loading to investigate the effect of altered loading on the initiation of these detrimental changes. We created supraspinatus and infraspinatus rotator cuff tears in the rat and followed these tears with either increased or decreased loading. Mechanical properties were determined along the length of the biceps tendon 4 and 8 weeks following injury. At the insertion site, stiffness increased with decreased loading, while detrimental changes were seen with increased loading 4 weeks following detachments. Increased loading resulted in decreased mechanical properties along the entire tendon length at both time points. Decreased loading resulted in both increased and decreased tendon properties at different regions of the tendon at 4 weeks, but by 8 weeks, there were no differences between decreased loading and detachment alone. We could not conclude where changes begin in the tendon with altered loading, but did demonstrate that regional differences exist. These results support that there is an effect of altered loading, as decreased loading resulted in variable changes at 4 weeks that were no different from detachment alone by 8 weeks, and increased loading resulted in detrimental properties along the entire length at both 4 and 8 weeks.     

Contributions of the individual muscles of the shoulder to glenohumeral joint stability during abduction

The aim of this study was to determine the relative contributions of the deltoid and rotator cuff muscles to glenohumeral joint stability during arm abduction. A three-dimensional model of the upper limb was used to calculate the muscle and joint-contact forces at the shoulder for abduction in the scapular plane. The joints of the shoulder girdle-sternoclavicular joint, acromioclavicular joint, and glenohumeral joint-were each represented as an ideal three degree-of-freedom ball-and-socket joint. The articulation between the scapula and thorax was modeled using two kinematic constraints. Eighteen muscle bundles were used to represent the lines of action of 11 muscle groups spanning the glenohumeral joint. The three-dimensional positions of the clavicle, scapula, and humerus during abduction were measured using intracortical bone pins implanted into one subject. The measured bone positions were inputted into the model, and an optimization problem was solved to calculate the forces developed by the shoulder muscles for abduction in the scapular plane. The model calculations showed that the rotator cuff muscles (specifically, supraspinatus, subscapularis, and infraspinatus) by virtue of their lines of action are perfectly positioned to apply compressive load across the glenohumeral joint, and that these muscles contribute most significantly to shoulder joint stability during abduction. The middle deltoid provides most of the compressive force acting between the humeral head and the glenoid, but this muscle also creates most of the shear, and so its contribution to joint stability is less than that of any of the rotator cuff muscles.     

Comparison of an EMG-based and a stress-based method to predict shoulder muscle forces

The estimation of muscle forces in musculoskeletal shoulder models is still controversial. Two different methods are widely used to solve the indeterminacy of the system: electromyography (EMG)-based methods and stress-based methods. The goal of this work was to evaluate the influence of these two methods on the prediction of muscle forces, glenohumeral load and joint stability after total shoulder arthroplasty. An EMG-based and a stress-based method were implemented into the same musculoskeletal shoulder model. The model replicated the glenohumeral joint after total shoulder arthroplasty. It contained the scapula, the humerus, the joint prosthesis, the rotator cuff muscles supraspinatus, subscapularis and infraspinatus and the middle, anterior and posterior deltoid muscles. A movement of abduction was simulated in the plane of the scapula. The EMG-based method replicated muscular activity of experimentally measured EMG. The stress-based method minimised a cost function based on muscle stresses. We compared muscle forces, joint reaction force, articular contact pressure and translation of the humeral head. The stress-based method predicted a lower force of the rotator cuff muscles. This was partly counter-balanced by a higher force of the middle part of the deltoid muscle. As a consequence, the stress-based method predicted a lower joint load (16% reduced) and a higher superior–inferior translation of the humeral head (increased by 1.2 mm). The EMG-based method has the advantage of replicating the observed cocontraction of stabilising muscles of the rotator cuff. This method is, however, limited to available EMG measurements. The stress-based method has thus an advantage of flexibility, but may overestimate glenohumeral subluxation.     

Biceps tenotomy in the presence of a supraspinatus tear alters the adjacent intact tendons and glenoid cartilage

A rotator cuff tear is a common injury in athletes and workers who repeatedly perform overhead movements, and it is not uncommon for this demographic to return to activity shortly after treatment. A biceps tenotomy is often performed in the presence of a rotator cuff tear to help reduce pain and improve joint function. However, the effect of this procedure on the surrounding tissues in the glenohumeral joint is unknown. Therefore, the purpose of this study was to investigate the effect of a biceps tenotomy in the presence of a supraspinatus rotator cuff tear followed by overuse activity on ambulatory function and mechanical and histologic properties of the remaining rotator cuff tendons and glenoid cartilage. 46 rats underwent 4 weeks of overuse activity to create a tendinopathic condition, then were randomized into two groups: unilateral detachment of the supraspinatus tendon or detachment of the supraspinatus and long head of the biceps tendons. Ambulatory measurements were performed throughout the 8 weeks prior to euthanasia, followed by analysis of the properties of the remaining intact tendons and glenoid cartilage. Results demonstrate that shoulder function was not effected in the biceps tenotomy group. However, the intact tendons and glenoid cartilage showed altered mechanical and histologic properties. This study provides evidence from an animal model that does not support the use of tenotomy in the presence of a supraspinatus tendon rotator cuff tear, and provides a framework for physicians to better prescribe long-term treatment strategies for patients.     

Stability of reconstructed paralyzed shoulders using a reflected long head biceps technique

A new tendon transfer technique is proposed for the reconstruction of the paralyzed shoulders secondary to Brachial Plexus Injury (BPI). In this tendon transfer, the long head of the biceps tendons is utilized as a bridging tendon graft. It is reflected at the exit of the bicipital groove, passed through the deltoid and directed to the trapezius. The technique is referred to here as the Reflected Long Head Bicepts (RLHB) technique. This study evaluated the effect of this tendon transfer on the anterior, posterior, and inferior stability of the reconstructed should using cadaveric specimens. It was shown that loading of the RLHB contributed significantly to anterior stability of the reconstructed shoulder for 90 deg elevation in the scapula plane. The mean displacement was reduced by 56 percent with RLHB loaded (p<0.01), by 56 percent with the rotator cuff loaded (p <0.005), and by 67 percent with both the RLHB and the rotator cuff loaded (p<0.004). For the post-operation conditions, variation of the directions of RLHB had no significant effect on joint displacement in response to anterior loading. The RLHB tendon also contributed to the posterior and inferior stability for the low and middle elevations in the plane of scapula. Two variations of the RLHB tendon transfer procedures, namely the "Sub-Deltoid" and the "Through-Deltoid" techniques, were introduced and studied. These two techniques did not seem to have significantly different effects on the displacement of the humeral head in response to both posterior and inferior loading. The results of this study seemed to support the clinical feasibility of this tendon transfer approach as far as the biomedical stability of the reconstruction is concerned.     

Effect of biceps-to-triceps transfer on rotator cuff stress during upper limb weight-bearing lift in tetraplegia: A modeling and simulation analysis

Rotator cuff stress during upper limb weight-bearing lifts presumably contribute to rotator cuff disease, which is the most common cause of shoulder pain in individuals with tetraplegia. Elbow extension strength appears to be a key determinant of rotator cuff stress during upper limb weight-bearing lifts since individuals with paraplegia who generate greater elbow extensor moments experience lower rotator cuff stress relative to individuals with tetraplegia. Biceps-to-triceps transfer surgery can increase elbow extension strength in individuals with tetraplegia. The purpose of this study was to determine whether active elbow extension via biceps transfer decreases rotator cuff stress during weight-bearing lifts in individuals with tetraplegia. A forward dynamics computational framework was used to estimate muscle stress during the lift; stress was computed as muscle force divided by the peak isometric muscle force. We hypothesized that rotator cuff stresses would be lower in simulated lifting with biceps transfer relative to simulated lifting without biceps transfer. We found that limited elbow extension strength in individuals with tetraplegia, regardless of whether elbow strength is enabled via biceps transfer or is residual after spinal cord injury, results in muscle stresses exceeding 85% of the peak isometric muscle stress in the supraspinatus, infraspinatus, and teres minor. The rotator cuff stresses we estimated suggest that performance of weight-bearing activities should be minimized or assisted in order to reduce the risk for shoulder pain. Our results also indicate that biceps transfer is unlikely to decrease rotator cuff stress during weight-bearing lifts in individuals with tetraplegia.     

Rotator cuff tendon strain correlates with tear propagation

Rotator cuff tears are a common tendon injury often requiring surgical treatment. Understanding the relationships between tear size, tendon loading, and tendon strain adjacent to a rotator cuff tear can provide important insights into predicting the likelihood of propagation to larger tears which would influence clinical treatment. Previous studies assume that an increase in strain correlates with an increase in risk of tear propagation. However, these studies did not explicitly investigate these important relationships. Therefore, the objective of this study was to quantify two-dimensional strain fields adjacent to a rotator cuff tendon tear under loading to failure and to assess the relationship between tendon strain and tear size. Sheep infraspinatus tendons were used to evaluate the effect of tear size on principal strains in the region adjacent to the tear. The relationship between strain, tear propagation, and the direction of tear propagation was quantified. Results showed that principal strains linearly correlated with tear propagation and that tear propagation began at strains as low as 1.7%. In addition, tears propagated in the direction of highest maximum and lowest minimum principal strain. Finally, maximum and minimum principal strains were higher and lower, respectively, adjacent to larger tears compared to smaller tears. Findings from this study validate the use of local strain adjacent to a rotator cuff tear as an indicator of the risk and direction of tear propagation.     

Effects of rotator cuff tears on muscle moment arms: a computational study

Rotator cuff tears cause morphologic changes to cuff tendons and muscles, which can alter muscle architecture and moment arm. The effects of these alterations on shoulder mechanical performance in terms of muscle force and joint strength are not well understood. The purpose of this study was to develop a three-dimensional explicit finite element model for investigating morphological changes to rotator cuff tendons following cuff tear. The subsequent objectives were to validate the model by comparing model-predicted moment arms to empirical data, and to use the model to investigate the hypothesis that rotator cuff muscle moment arms are reduced when tendons are divided along the force-bearing direction of the tendon. The model was constructed by extracting tendon, cartilage, and bone geometry from the male Visible Human data set. Infraspinatus and teres minor muscle and tendon paths were identified relative to the humerus and scapula. Kinetic and kinematic boundary conditions in the model replicated experimental protocols, which rotated the humerus from 45 degrees internal to 45 degrees external rotation with constant loads on the tendons. External rotation moment arms were calculated for two conditions of the cuff tendons: intact normal and divided tendon. Predicted moment arms were within the 1-99% confidence intervals of experimental data for nearly all joint angles and tendon sub-regions. In agreement with the experimental findings, when compared to the intact condition, predicted moment arms were reduced for the divided tendon condition. The results of this study provide evidence that one potential mechanism for the reduction in strength observed with cuff tear is reduction of muscle moment arms. The model provides a platform for future studies addressing mechanisms responsible for reduced muscle force and joint strength including changes to muscle length-tension operating range due to altered muscle and tendon excursions, and the effects of cuff tear size and location on moment arms and muscle forces.     

Development of an Arthroscopic Joint Capsule Injury Model in the Canine Shoulder

Background

The natural history of rotator cuff tears can be unfavorable as patients develop fatty infiltration and muscle atrophy that is often associated with a loss of muscle strength and shoulder function. To facilitate study of possible biologic mechanisms involved in early degenerative changes to rotator cuff muscle and tendon tissues, the objective of this study was to develop a joint capsule injury model in the canine shoulder using arthroscopy.

Methods

Arthroscopic surgical methods for performing a posterior joint capsulectomy in the canine shoulder were first defined in cadavers. Subsequently, one canine subject underwent bilateral shoulder joint capsulectomy using arthroscopy, arthroscopic surveillance at 2, 4 and 8 weeks, and gross and histologic examination of the joint at 10 weeks.

Results

The canine subject was weight-bearing within eight hours after index and follow-up surgeries and had no significant soft tissue swelling of the shoulder girdle or gross lameness. Chronic synovitis and macroscopic and microscopic evidence of pathologic changes to the rotator cuff bony insertions, tendons, myotendinous junctions and muscles were observed.

Conclusions

This study demonstrates feasibility and proof-of-concept for a joint capsule injury model in the canine shoulder. Future work is needed to define the observed pathologic changes and their role in the progression of rotator cuff disease. Ultimately, better understanding of the biologic mechanisms of early progression of rotator cuff disease may lead to clinical interventions to halt or slow this process and avoid the more advanced and often irreversible conditions of large tendon tears with muscle fatty atrophy.     

Differences in glutamate receptors and inflammatory cell numbers are associated with the resolution of pain in human rotator cuff tendinopathy

IntroductionThe relationship between peripheral tissue characteristics and pain symptoms in soft tissue inflammation is poorly understood. The primary aim of this study was to determine immunohistochemical differences in tissue obtained from patients with persistent pain and patients who had become pain-free after surgical treatment for rotator cuff tendinopathy. The secondary aim was to investigate whether there would be differences in glutaminergic and inflammatory gene expression between disease-derived and healthy control cells in vitro.MethodsSupraspinatus tendon biopsies were obtained from nine patients with tendon pain before shoulder surgery and from nine further patients whose pain had resolved completely following shoulder surgery. Histological markers relating to the basic tendon characteristics, inflammation and glutaminergic signalling were quantified by immunohistochemical analysis. Gene expression of glutaminergic and inflammatory markers was determined in tenocyte explants derived from painful rotator cuff tendon tears in a separate cohort of patients and compared to that of explants from healthy control tendons. Dual labelling was performed to identify cell types expressing nociceptive neuromodulators.ResultsTendon samples from patients with persistent pain demonstrated increased levels of metabotropic glutamate receptor 2 (mGluR2), kainate receptor 1 (KA1), protein gene product 9.5 (PGP9.5), CD206 (macrophage marker) and CD45 (pan-leucocyte marker) versus pain-free controls (p <0.05). NMDAR1 co-localised with CD206-positive cells, whereas PGP9.5 and glutamate were predominantly expressed by resident tendon cells. These results were validated by in vitro increases in the expression of mGluR2, N-methyl-D-aspartate receptor (NMDAR1), KA1, CD45, CD206 and tumour necrosis factor alpha (TNF-α) genes (p <0.05) in disease-derived versus control cells.ConclusionsWe conclude that differences in glutamate receptors and inflammatory cell numbers are associated with the resolution of shoulder pain in rotator cuff tendinopathy, and that disease-derived cells exhibit a distinctly different neuro-inflammatory gene expression profile to healthy control cells.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0691-5) contains supplementary material, which is available to authorized users.     

Tendon to bone healing: differences in biomechanical,structural, and compositional properties due to a range of activity levels

Little knowledge exists about the healing process of the tendon to bone insertion, and hence little can be done to improve tissue healing. The goal of this study is to describe the healing of the supraspinatus tendon to its bony insertion under a variety of loading conditions. Tendons were surgically detached and repaired in rats. Rat shoulders were then immobilized, allowed cage activity, or exercised. Shoulders that were immobilized demonstrated superior structural (significantly higher collagen orientation), compositional (expression of extracellular matrix genes similar to the uninjured insertion), and quasilinear viscoelastic properties (A = 0.30 +/- 0.10 MPa vs. 0.16 +/- 0.08 MPa, B = 17.4 +/- 2.9 vs. 15.1 +/- 0.9, and tau 2 = 344 +/- 161 s vs. 233 +/- 40 s) compared to those that were exercised, contrary to expectations. With this knowledge of the healing response, treatment modalities for rotator cuff tears can be developed.     

肩袖间隙影像解剖及常见病变的研究进展

肩袖间隙在解剖学上是肩关节的一个复合区域,在维持肩关节稳定性和保护肱二头肌长头肌腱功能起重要作用。对肩袖间隙解剖结构及功能的深入认识有助于肩袖间隙损伤性病变、挛缩性病变等的及时诊断和合理治疗。影像学检查尤其是磁共振逐步成为肩袖间隙疾病最主要的检查方法,包括常规扫描、直接及间接性磁共振肩关节造影、增强扫描等。本文将就肩袖间隙的影像解剖及常见病变的相关研究进行综述。     

Suprascapular nerve block results in a compensatory increase in deltoid muscle activity

A balance exists between the deltoid and rotator cuff contribution to arm elevation. Both cadaver and computer models have predicted an increase in deltoid muscle force with dysfunction of the rotator cuff. The goal of the present study was to verify this phenomenon in vivo by examining the effects of paralysis of the supraspinatus and infraspinatus muscles with a suprascapular nerve block on the electrical activity of seven shoulder muscles. Electromyographic data were collected before and after the administration of the block. The block resulted in a significant increase in muscle activity for all heads of the deltoid, with a higher percentage increase noted at lower elevation angles. Although the deltoid activity was reduced as the subjects recovered from the block, even low levels of cuff dysfunction were found to result in increased deltoid activity. These results suggest that even small disruptions in the normal function of some rotator cuff muscles (e.g., due to fatigue or impingement syndrome), may result in an increase in deltoid activity. It is possible that such compensation may result in higher superior loads at the glenohumeral joint, possibly increasing the risk of tendon damage.     

Sub-regional activation of supraspinatus and infraspinatus muscles during activities of daily living is task dependent

The supraspinatus and infraspinatus muscles each have multiple sub-regions that may activate differentially in activities of daily living. Awareness of these differential demands critically informs rehabilitation of rotator cuff muscle following injury, particularly if centered on recovering and strengthening the rotator cuff to perform daily tasks. This study quantified muscle activation of supraspinatus and infraspinatus sub-regions during the performance of six activities of daily living. Twenty-three participants (mean: 22.6 ± 2.6 years) completed the following tasks: opening a jar, reaching at shoulder height, overhead reaching, pouring water from a pitcher, eating with a spoon, and combing hair. Indwelling electromyography was collected from the anterior and posterior supraspinatus and superior, middle, and inferior infraspinatus. Tasks requiring high arm elevations (e.g. reaching at shoulder and overhead height) activated anterior supraspinatus between 21 and 28% MVC. The posterior supraspinatus consistently activated between 10 and 30% MVC across all tasks. All sub-regions of infraspinatus activated highly (between 18 and 25% MVC) in tasks requiring high arm elevations in flexion. These findings may be leveraged to define effective measures to increase rotator cuff function in daily tasks.     

The effect of the trabecular microstructure on the pullout strength of suture anchors

This study investigates how the microstructural properties of trabecular bone affect suture anchor performance. Seven fresh-frozen humeri were tested for pullout strength with a 5 mm Arthrex Corkscrew in the greater tuberosity, lesser tuberosity, and humeral head. Micro-computed tomography analysis was performed in the three regions of interest directly adjacent to individual pullout experiments. The morphometric properties of bone mineral density (BMD), structural model index (SMI), trabecular thickness (TbTh), trabecular spacing (TbS), trabecular number (TbN), and connectivity density were compared against suture anchor pullout strength. BMD (r=0.64), SMI (r=?0.81), and TbTh (r=0.71) showed linear correlations to the pullout strength of the suture anchor with p-values<0.0001. A predictive model was developed to explain the variances in the individual BMD, SMI, and TbTh correlations. The multi-variant model of pullout strength showed a stronger relationship (r=0.86) compared to the individual experimental results. This study helps confirm BMD is a major influence on the pullout strength of suture anchors, but also illustrates the importance of local microstructure in pullout resistance of suture anchors.