Biomechanical and structural response of healing Achilles tendon to fatigue loading following acute injury

Achilles tendon injuries affect both athletes and the general population, and their incidence is rising. In particular, the Achilles tendon is subject to dynamic loading at or near failure loads during activity, and fatigue induced damage is likely a contributing factor to ultimate tendon failure. Unfortunately, little is known about how injured Achilles tendons respond mechanically and structurally to fatigue loading during healing. Knowledge of these properties remains critical to best evaluate tendon damage induction and the ability of the tendon to maintain mechanical properties with repeated loading. Thus, this study investigated the mechanical and structural changes in healing mouse Achilles tendons during fatigue loading. Twenty four mice received bilateral full thickness, partial width excisional injuries to their Achilles tendons (IACUC approved) and twelve tendons from six uninjured mice were used as controls. Tendons were fatigue loaded to assess mechanical and structural properties simultaneously after 0, 1, 3, and 6 weeks of healing using an integrated polarized light system. Results showed that the number of cycles to failure decreased dramatically (37-fold, p<0.005) due to injury, but increased throughout healing, ultimately recovering after 6 weeks. The tangent stiffness, hysteresis, and dynamic modulus did not improve with healing (p<0.005). Linear regression analysis was used to determine relationships between mechanical and structural properties. Of tendon structural properties, the apparent birefringence was able to best predict dynamic modulus (R²=0.88–0.92) throughout healing and fatigue life. This study reinforces the concept that fatigue loading is a sensitive metric to assess tendon healing and demonstrates potential structural metrics to predict mechanical properties.     

Fatigue loading of tendon results in collagen kinking and denaturation but does not change local tissue mechanics

Fatigue loading is a primary cause of tendon degeneration, which is characterized by the disruption of collagen fibers and the appearance of abnormal (e.g., cartilaginous, fatty, calcified) tissue deposits. The formation of such abnormal deposits, which further weakens the tissue, suggests that resident tendon cells acquire an aberrant phenotype in response to fatigue damage and the resulting altered mechanical microenvironment. While fatigue loading produces clear changes in collagen organization and molecular denaturation, no data exist regarding the effect of fatigue on the local tissue mechanical properties. Therefore, the objective of this study was to identify changes in the local tissue stiffness of tendons after fatigue loading. We hypothesized that fatigue damage would reduce local tissue stiffness, particularly in areas with significant structural damage (e.g., collagen denaturation). We tested this hypothesis by identifying regions of local fatigue damage (i.e., collagen fiber kinking and molecular denaturation) via histologic imaging and by measuring the local tissue modulus within these regions via atomic force microscopy (AFM). Counter to our initial hypothesis, we found no change in the local tissue modulus as a consequence of fatigue loading, despite widespread fiber kinking and collagen denaturation. These data suggest that immediate changes in topography and tissue structure – but not local tissue mechanics – initiate the early changes in tendon cell phenotype as a consequence of fatigue loading that ultimately culminate in tendon degeneration.     

The influence of ageing and exercise on tendon growth and degeneration--hypotheses for the initiation and prevention of strain-induced tendinopathies

Strain-induced tendinopathy is a common injury in both human and equine athletes, with increasing incidence associated with greater involvement in sport and an increasingly aged population. This paper reviews our studies on the abundant non-collagenous protein, cartilage oligomeric matrix protein (COMP), in equine tendons. Its variation between tendon type and site, age and exercise has provided an insight into how age and exercise influence tendon growth and maturation. Tendons can be broadly divided into two types, reflecting their different matrix composition and function: the energy-storing tendons used for weight-bearing and locomotion, which suffer a high incidence of strain-induced tendinopathy, and positional tendons involved in limb placement or manipulative skills. It would appear that while energy-storing tendon can respond to the mechanical forces applied to it during growth, there is no evidence that it can do so after skeletal maturity. Instead, cumulative fatigue damage causes degeneration at the molecular level, potentially weakening it and increasing the risk of clinical injury. Appropriate exercise regimes early in life may help to improve the quality of growing tendon, thereby reducing the incidence of injury during ageing or subsequent athletic career.     

Mechanical,histological, and functional properties remain inferior in conservatively treated Achilles tendons in rodents: Long term evaluation

Conservative treatment (non-operative) of Achilles tendon ruptures is suggested to produce equivalent capacity for return to function; however, long term results and the role of return to activity (RTA) for this treatment paradigm remain unclear. Therefore, the objective of this study was to evaluate the long term response of conservatively treated Achilles tendons in rodents with varied RTA. Sprague Dawley rats (n = 32) received unilateral blunt transection of the Achilles tendon followed by randomization into groups that returned to activity after 1-week (RTA1) or 3-weeks (RTA3) of limb casting in plantarflexion, before being euthanized at 16-weeks post-injury. Uninjured age-matched control animals were used as a control group (n = 10). Limb function, passive joint mechanics, tendon properties (mechanical, histological), and muscle properties (histological, immunohistochemical) were evaluated. Results showed that although hindlimb ground reaction forces and range of motion returned to baseline levels by 16-weeks post-injury regardless of RTA, ankle joint stiffness remained altered. RTA1 and RTA3 groups both exhibited no differences in fatigue properties; however, the secant modulus, hysteresis, and laxity were inferior compared to uninjured age-matched control tendons. Despite these changes, tendons 16-weeks post-injury achieved secant stiffness levels of uninjured tendons. RTA1 and RTA3 groups had no differences in histological properties, but had higher cell numbers compared to control tendons. No changes in gastrocnemius fiber size or type in the superficial or deep regions were detected, except for type 2x fiber fraction. Together, this work highlights RTA-dependent deficits in limb function and tissue-level properties in long-term Achilles tendon and muscle healing.     

The relationships between cyclic fatigue loading, changes in initial mechanical properties, and the in vivo temporal mechanical response of the rat patellar tendon

Damage accumulation underlies tendinopathy. Animal models of overuse injuries do not typically control loads applied to the tendon. Our in vivo model in the rat patellar tendon allows direct control of the loading applied to the tendon. Despite this advantage, natural variation among tendons results in different amounts of damage induced by the same loading protocol. Our objectives were to (1) assess changes in the initial mechanical parameters (hysteresis, stiffness of the loading and unloading load-displacement curves, and elongation) after fatigue loading to identify parameters that are indicative of the induced damage, and (2) evaluate the relationships between these identified initial damage indices with the stiffness 7 day after loading. Left patellar tendons of adult, female retired breeder, Sprague-Dawley rats (n = 68) were fatigue loaded per our previously published in vivo fatigue loading protocol. To induce a range of damage, fatigue loading consisted of either 5, 100, 500 or 7200 cycles that ranged from 1 N to 40 N. Diagnostic tests were applied before and immediately after fatigue loading, and after 45 min of recovery to deduce recoverable and non-recoverable changes in initial damage indices. Relationships between these initial damage indices and the 7-day stiffness (at sacrifice) were determined. Day-0 hysteresis, loading and unloading stiffness exhibited cycle-dependent changes. Initial hysteresis loss correlated with the 7-day stiffness. k-means cluster analysis demonstrated a relationship between 7-day stiffness and day-0 hysteresis and unloading stiffness. This analysis also separated samples that exhibited low from high damage in response to both high or low number of cycles; a key delineation for interpretation of the biological response in future studies. Identifying initial parameters that reflect the induced damage is critical since the ability of the tendon to repair depends on the damage induced and the number of applied loading cycles.     

Early response to tendon fatigue damage accumulation in a novel in vivo model

This study describes the development and application of a novel rat patellar tendon model of mechanical fatigue for investigating the early in vivo response to tendon subfailure injury. Patellar tendons of adult female Sprague-Dawley rats were fatigue loaded between 1–35 N using a custom-designed loading apparatus. Patellar tendons were subjected to Low-, Moderate- or High-level fatigue damage, defined by grip-to-grip strain measurement. Molecular response was compared with that of a laceration-repair injury. Histological analyses showed that progression of tendon fatigue involves formation of localized kinked fiber deformations at Low damage, which increased in density with presence of fiber delaminations at Moderate damage, and fiber angulation and discontinuities at High damage levels. RT-PCR analysis performed at 1- and 3-day post-fatigue showed variable changes in type I, III and V collagen mRNA expression at Low and Moderate damage levels, consistent with clinical findings of tendon pathology and were modest compared with those observed at High damage levels, in which expression of all collagens evaluated were increased markedly. In contrast, only type I collagen expression was elevated at the same time points post-laceration. Findings suggest that cumulative fatigue in tendon invokes a different molecular response than laceration. Further, structural repair may not be initiated until reaching end-stage fatigue life, where the repair response may unable to restore the damaged tendon to its pre-fatigue architecture.     

Fatigue damage of human tendons

The study was designed to examine the effects of partial fatigue on specific mechanical parameters which characterise human tendons in vitro. Specimens prepared from 12 intact Extensor digitorum longus tendons of the foot were subjected to partial fatigue, equivalent to 25% of the median fatigue life, by a cyclic square tension-tension stress waveform at the physiological frequency of 4 Hz. The maximum stress was set at a value corresponding to 20% of the calculated ultimate tensile strength (UTS) of 100 MPa. The minimum stress was set at 1% of the UTS. Dynamic characterisation was performed at stress levels of 10% and 20% of the UTS prior to and following partial mechanical fatigue. Subsequent quasi-static tests were performed on some of the specimens. Comparative analysis of the damage ratios (DRs) of quasi-static and dynamic mechanical parameters suggested the use of the DR for dynamic tensile modulus as a good indicator of damage inflicted by mechanical fatigue. Such an approach might be used for an in vivo assessment of tendon damage.     

Effects of long-term exercise on the biomechanical properties of the Achilles tendon of guinea fowl

The purpose of this study wasto determine the effect of long-term exercise on tendon compliance andto ascertain whether tendons adapt differently to downhill running vs.running on a level surface. We carried out this investigation on thegastrocnemius tendon of helmeted guinea fowl (Numidameleagris) that were trained for 8-12 wk before commencingexperimental procedures. We used an in situ technique to measure tendonstiffness. The animals were deeply anesthetized with isofluorane duringall in situ procedures. Our results indicate that long-term exerciseincreased tendon stiffness. This finding held true after normalizationfor the cross-sectional area of the free tendon, likely reflecting achange in the material properties of the exercised tendons. Whethertraining consisted of level or downhill running did not appear toinfluence response of the tendon to exercise. We hypothesize that theincreased stiffness observed in tendons after a long-term runningprogram may be a response to repeated stress and may function as amechanism to resist tendon damage due to mechanical fatigue.

     

Variations in collagen fibril structure in tendons

Variation of collagen fibril structure in tendon was investigated by x-ray diffraction. Anatomically distinct tendons from single species, as well as tendons from different species, were examined to determine the variations that exist in both the axial and lateral structure of the collagen fibrils. The meridional diffraction is derived from the axial collagen fibril structure. Anatomically distinct tendons of a particular species give meridional patterns that are indistinguishable within experimental error. The meridional diffraction patterns from tendons of different mammals are similar but show small species-specific variations, most noticeably in the 14th–18th orders. Tendons of birds also give meridional patterns that are similar to each other, but the avian patterns differ considerably from the mammalian ones. Avian tendons give stronger odd and weaker even low orders, a feature consistent with a reduced gap:overlap ratio, and have a distinctive intensity pattern for the higher meridional orders. Interpretation of these differences has been approached using biochemical data, diffraction by reconsituted fibers of purified collagen, and Fourier transform analysis. From these methods, it appears that the variations observed in the lower orders (2nd–8th) and in the higher orders (29th–52nd) are probably related to differences in the primary structure of the Type I collagen found in the different species. The variations observed in the 14th–18th orders appear not to be related to features within the triple-helical domain of the molecule. Equatorial diffraction yields information on the lateral packing of collagen molecules in the fibrils, and considerable variation was seen in different tendons. Rat tail tendon gives sharp Bragg reflections, demonstrating the presence of a crystalline lateral arrangement of molecules in the fibril. For the first time, sharp lattice reflections similar to those in rat tail tendon have been observed in nontail tendons, including rat achilles tendon, rabbit leg tendon, and wing and leg tendons of quail. In the rabbit and quail tendons, one of the strong equatorial reflections characteristic of the rat tendon pattern, at 1.26 nm, was absent. The positions of the equatorial maxima, which are a measure of intermolecular spacing, varied considerably, being smallest in the specimens displaying crystalline packing. The intermolecular distance in chiken and turkey leg tendons is longer than that found in mammalian tendons, or in avian wing tendons, which supports the hypothesis that a larger intermolecular spacing is characteristic of tendons that calcify. Thus, x-ray diffraction indicates there are reproducible differences in both the axial and lateral structure of collagen fibrils among different tendons. This work on tendon, a tissue containing almost exclusively Type I collagen as its major component, should serve as a basis for analyzing the structure of other connective tissues, which contain different genetic types of collagen and larger amounts of noncollagenous components.     

Regional Differences in Elements of Human Peroneus LongusTendons

Many studies have been performed on the structure, molecular composition, and biochemical properties of tendons. However, comparatively little research has been conducted on the content of various trace elements within tendons. Six elements were analyzed in four regions of the peroneus longus tendon: the tensional part of the tendon immediately proximal to the lateral malleolus (region A), the compressive region of the tendon in contact with the lateral malleolus (region B), the compressive region of the tendon in contact with the deep surface of the cuboid (region C), and the tensional part of the tendon between the cuboid and first metatarsal, to which the tendon is attached (region D). Regions B and C are wraparound regions. The calcium content was higher in region C (2.10?±?0.93 mg/g) than in both regions A (1.25?±?0.51 mg/g) and D (1.43?±?0.41 mg/g) (p?<?0.05), indicating that it is likely related to regional differences in cartilage degeneration. The phosphorus content was also higher in region C, possibly because of low alkaline phosphatase activity in this region. The sulfur content was higher in the wraparound regions (region B: 0.98?±?0.09 mg/g, region C: 1.24?±?0.19 mg/g) than in both regions A (0.83?±?0.11 mg/g) and D (0.83?±?0.1 mg/g) (p?<?0.01); sulfur content is thought to be influenced by tendon–bone compression. Finally, the magnesium content in the wraparound regions was also higher, which is probably related to a higher level of fibrocartilage. No significant relationships were found with regard to zinc or iron. Overall, the findings of the present study indicate that element contents are related to function and anatomical differences in tendons, and that they may even vary within the same tendon.     

A novel application of the principles of linear elastic fracture mechanics (LEFM) to the fatigue behavior of tendon tissue

BACKGROUND: Experiments on the fatigue of tendons have shown that cyclic loading induces failure at stresses lower than the ultimate tensile strength (UTS) of the tendons. The number of cycles to failure (Nf) has been shown to be dependent upon the magnitude of the applied cyclic stress. METHOD OF APPROACH: Utilizing data collected by Schechtman (1995), we demonstrate that the principles of Linear Elastic Fracture Mechanics (LEFM) can be used to predict the fatigue behavior of tendons under cyclic loading for maximum stress levels that are higher than 10% of the ultimate tensile strength (UTS) of the tendon (the experimental results at 10% UTS did not fit with our equations). CONCLUSIONS: LEFM and other FM approaches may prove to be very valuable in advancing our understanding of damage accumulation in soft connective tissues.     

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

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

In situ fibril stretch and sliding is location-dependent in mouse supraspinatus tendons

Tendons are able to transmit high loads efficiently due to their finely optimized hierarchical collagen structure. Two mechanisms by which tendons respond to load are collagen fibril sliding and deformation (stretch). Although many studies have demonstrated that regional variations in tendon structure, composition, and organization contribute to the full tendon׳s mechanical response, the location-dependent response to loading at the fibril level has not been investigated. In addition, the instantaneous response of fibrils to loading, which is clinically relevant for repetitive stretch or fatigue injuries, has also not been studied. Therefore, the purpose of this study was to quantify the instantaneous response of collagen fibrils throughout a mechanical loading protocol, both in the insertion site and in the midsubstance of the mouse supraspinatus tendon. Utilizing a novel atomic force microscopy-based imaging technique, tendons at various strain levels were directly visualized and analyzed for changes in fibril d-period with increasing tendon strain. At the insertion site, d-period significantly increased from 0% to 1% tendon strain, increased again from 3% to 5% strain, and decreased after 5% strain. At the midsubstance, d-period increased from 0% to 1% strain and then decreased after 7% strain. In addition, fibril d-period heterogeneity (fibril sliding) was present, primarily at 3% strain with a large majority occurring in the tendon midsubstance. This study builds upon previous work by adding information on the instantaneous and regional-dependent fibrillar response to mechanical loading and presents data proposing that collagen fibril sliding and stretch are directly related to tissue organization and function.     

Tendon extracellular matrix damage detection and quantification using automated edge detection analysis

The accumulation of sub-rupture tendon fatigue damage in the extracellular matrix, particularly of type I collagen fibrils, is thought to contribute to the development of tendinopathy, a chronic and degenerative pathology of tendons. Quantitative assessment of collagen fibril alignment is paramount to understanding the importance of matrix injury to cellular function and remodeling capabilities. This study presents a novel application of edge detection analysis to calculate local collagen fibril orientation in tendon. This technique incorporates damage segmentation and stratification by severity which will allow future analysis of the direct effect of matrix damage severity on the cellular and molecular response.     

Is phylogeny driving tendon length in lizards?

Tulli, M.J., Herrel, A., Vanhooydonck, B. and Abdala, V. 2012. Is phylogeny driving tendon length in lizards?—Acta Zoologica (Stockholm) 93 : 319–329. Tendons transmit tensile forces generated by muscles and are a crucial part of the musculoskeletal system in vertebrates. Because tendons and tendon cells respond to altered mechanical load by increasing collagen synthesis, we hypothesized that a correlation between tendon morphology and the loading regime imposed by locomotor style or habitat use exists. This makes tendons an interesting model for studying the relationship between morphology and environment. In this study, we compare the general morphology of the palmar flexor plate, the length of the digital tendons, and the length of the flexor carpi ulnaris tendon in species of lizards that exploit a variety of structural habitats. The results from statistical analyses show that phylogenetic relatedness has a major impact on our ability to detect differences between habitat groups, and no differences in tendon length could be detected between iguanian species occupying different habitats when taking into account the relatedness between species. Our data for lizards diverge from the general mammalian paradigm where variation in tendon is often associated with habitat use or locomotor style.     

Neuropathogenesis of HIV-1 infection. Outstanding questions

Significant progress in understanding and treating acquired immunodeficiency syndrome (AIDS) has been made over the last 5 years. Current multi drug therapies prolong patients' lives and reduce the incidence of neurobehavioural symptoms. However, the impact of therapy on human immunodeficiency virus type one (HIV-1), the causative agent of AIDS, in the brain, is unknown. Some patients develop dementia in spite of the multi drug therapies and others develop subtle neurobehavioural changes that diminish the quality of their prolonged lives. Thus, HIV-1 infection of the central nervous system remains an important clinical concern. Although much is known about neuropathology of HIV-1 infection, major questions about neuropathogenesis remain. How does HIV-1 reach the brain? Is it present in neurons and glial cells? What is the biological and therapeutic significance of neurotropism of HIV-1? What causes neuronal damage and loss? And, is CNS a resevoir of HIV-1? More research in vivo and in situ in humans and in animals, is needed to answer these outstanding questions. Specific experiments addressing these questions are proposed.     

What happens when tendons bend and twist? Proteoglycans

When tendons must bend or twist in order to fulfil their function of attaching muscle to bone they are subjected to forces that could damage the tendon. However, there are concomitant protective changes in the structure of the tendon at the location of bending. One of these changes involves increased synthesis and accumulation of the large proteoglycan aggrecan. The accumulation of aggrecan can protect the tendon by providing compressive stiffness, by allowing collagen fascicles to slide relative to one another, and by protecting vascular elements.     

Tendon crimps and peritendinous tissues responding to tensional forces

Tendons transmit forces generated from muscle to bone making joint movements possible. Tendon collagen has a complex supramolecular structure forming many hierarchical levels of association; its main functional unit is the collagen fibril forming fibers and fascicles. Since tendons are enclosed by loose connective sheaths in continuity with muscle sheaths, it is likely that tendon sheaths could play a role in absorbing/transmitting the forces created by muscle contraction. In this study rat Achilles tendons were passively stretched in vivo to be observed at polarized light microscope (PLM), scanning electron microscope (SEM) and transmission electron microscope (TEM). At PLM tendon collagen fibers in relaxed rat Achilles tendons ran straight and parallel, showing a periodic crimp pattern. Similarly tendon sheaths showed apparent crimps. At higher magnification SEM and TEM revealed that in each tendon crimp large and heterogeneous collagen fibrils running straight and parallel suddenly changed their direction undergoing localized and variable modifications. These fibril modifications were named fibrillar crimps. Tendon sheaths displayed small and uniform fibrils running parallel with a wavy course without any ultrastructural aspects of crimp. Since in passively stretched Achilles tendons fibrillar crimps were still observed, it is likely that during the tendon stretching, and presumably during the tendon elongation in muscle contraction, the fibrillar crimp may be the real structural component of the tendon crimp acting as shock absorber. The peritendinous sheath can be stretched as tendon, but is not actively involved in the mechanism of shock absorber as the fibrillar crimp. The different functional behaviour of tendons and sheaths may be due to the different structural and molecular arrangement of their fibrils.     

Non-uniformity in the healthy patellar tendon is greater in males and similar in different age groups

There is increasing evidence that tendons are heterogeneous and take advantage of structural mechanisms to enhance performance and reduce injury. Fascicle-sliding, for example, is used by energy-storing tendons to enable them to undergo large extensions while protecting the fascicles from damage. Reductions in fascicle-sliding capacity may thus predispose certain populations to tendinopathy. Evidence from the Achilles tendon of significant superficial-to-deep non-uniformity that is reduced with age supports this theory. Similar patellar tendon non-uniformity has been observed, but the effects of age and sex have yet to be assessed. Healthy adults (n = 50, 25M/25F) from a broad range of ages (23–80) were recruited and non-uniformity was quantified using ultrasound speckle-tracking during passive knee extension. Significant superficial-to-deep non-uniformity and proximal/distal variations were observed. No effect of age was found, but males exhibited significantly greater non-uniformity than females (p < 0.05). The results contrast with previous findings in the Achilles tendon; in this study, tendons and tendon regions at high risk for tendinopathy (i.e. males and proximal regions, respectively) exhibited greater non-uniformity, whereas high-risk Achilles tendons (i.e. older adults) previously showed reduced non-uniformity. This suggests that non-uniformity may be dominated by factors other than fascicle-sliding. Anatomically, the varied proximal attachment of the patellar tendon may influence non-uniformity, with quadriceps passive resistance limiting superficial tendon movement, thus linking flexibility, non-uniformity and injury risk. This study also provides evidence of a differential effect of aging on the patellar tendon compared with evidence from prior studies on other tendons necessitating further study to elucidate links between non-uniformity and injury.