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.     

Does subcutaneous adipose tissue behave as an (anti-)thixotropic material?

Although subcutaneous adipose tissue undergoes large deformations on a daily basis, there is no adequate mechanical model to describe the transfer of mechanical load from the skin throughout the tissue to deeper layers. In order to develop such a non-linear model, a set of experimental data is required. Accordingly, this study examines the long term behavior of adipose tissue under small strain and its response to various large strain profiles. The results show that the shear modulus dramatically increases to about an order of magnitude after a loading period between 250 and 1250 s, but returns to its initial value within 3 h of recovery from loading. In addition, it was observed that the stress–strain responses for various large strain history sequences are reproducible up to a strain of 0.15. For increasing strains, the stress decreases for subsequent loading cycles and, above 0.3 strain, tissue structure changes such that the stress becomes independent of the applied strain. From the results, it can be concluded that adipose tissue likely behaves as an (anti-) thixotropic material and that a Mooney–Rivlin model might be appropriate to simulate behavior at physiologically relevant high strains. However, before the model is developed more fully, further experimental research is needed to ratify that the material is (anti-)thixotropic.     

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.     

A numerical framework for mechano-regulated tendon healing—Simulation of early regeneration of the Achilles tendon

Mechano-regulation during tendon healing, i.e. the relationship between mechanical stimuli and cellular response, has received more attention recently. However, the basic mechanobiological mechanisms governing tendon healing after a rupture are still not well-understood. Literature has reported spatial and temporal variations in the healing of ruptured tendon tissue. In this study, we explored a computational modeling approach to describe tendon healing. In particular, a novel 3D mechano-regulatory framework was developed to investigate spatio-temporal evolution of collagen content and orientation, and temporal evolution of tendon stiffness during early tendon healing. Based on an extensive literature search, two possible relationships were proposed to connect levels of mechanical stimuli to collagen production. Since literature remains unclear on strain-dependent collagen production at high levels of strain, the two investigated production laws explored the presence or absence of collagen production upon non-physiologically high levels of strain (>15%). Implementation in a finite element framework, pointed to large spatial variations in strain magnitudes within the callus tissue, which resulted in predictions of distinct spatial distributions of collagen over time. The simulations showed that the magnitude of strain was highest in the tendon core along the central axis, and decreased towards the outer periphery. Consequently, decreased levels of collagen production for high levels of tensile strain were shown to accurately predict the experimentally observed delayed collagen production in the tendon core. In addition, our healing framework predicted evolution of collagen orientation towards alignment with the tendon axis and the overall predicted tendon stiffness agreed well with experimental data. In this study, we explored the capability of a numerical model to describe spatial and temporal variations in tendon healing and we identified that understanding mechano-regulated collagen production can play a key role in explaining heterogeneities observed during tendon healing.     

The rigidity of repaired flexor tendons increases following ex vivo cyclic loading

Transected flexor tendons are typically treated by suture repair followed by rehabilitation that generates repetitive tendon loading. Recent results in an in vivo canine model indicate that during the first 10 days after injury and repair, there is an increase in the rigidity of the tendon repair site. Our objective was to determine whether or not ex vivo cyclic loading of repaired flexor tendons causes a similar increase in repair-site rigidity. We simulated 10 days of rehabilitation by applying 6000 loading cycles to repaired canine flexor tendons ex vivo at force levels generated during passive motion rehabilitation; we then evaluated their tensile mechanical properties. High-force (peak force, 17 N) cyclic loading increased repair-site rigidity by 100% and decreased repair-site strain by 50%, whereas low-force (5 N) loading did not change the properties of the repair site. This mechanical conditioning effect may explain, in part, the changes in tensile properties observed after only 10 days of healing in vivo. Mechanical conditioning of repaired flexor tendons by repetitive forces applied during rehabilitation may lead to increases in repair-site rigidity and decreases in strain, thereby altering the mechanical loading environment of tissues and cells at the repair site.     

Effect of preconditioning and stress relaxation on local collagen fiber re-alignment: inhomogeneous properties of rat supraspinatus tendon

Repeatedly and consistently measuring the mechanical properties of tendon is important but presents a challenge. Preconditioning can provide tendons with a consistent loading history to make comparisons between groups from mechanical testing experiments. However, the specific mechanisms occurring during preconditioning are unknown. Previous studies have suggested that microstructural changes, such as collagen fiber re-alignment, may be a result of preconditioning. Local collagen fiber re-alignment is quantified throughout tensile mechanical testing using a testing system integrated with a polarized light setup, consisting of a backlight, 90 deg-offset rotating polarizer sheets on each side of the test sample, and a digital camera, in a rat supraspinatus tendon model, and corresponding mechanical properties are measured. Local circular variance values are compared throughout the mechanical test to determine if and where collagen fiber re-alignment occurred. The inhomogeneity of the tendon is examined by comparing local circular variance values, optical moduli and optical transition strain values. Although the largest amount of collagen fiber re-alignment was found during preconditioning, significant re-alignment was also demonstrated in the toe and linear regions of the mechanical test. No significant changes in re-alignment were seen during stress relaxation. The insertion site of the supraspinatus tendon demonstrated a lower linear modulus and a more disorganized collagen fiber distribution throughout all mechanical testing points compared to the tendon midsubstance. This study identified a correlation between collagen fiber re-alignment and preconditioning and suggests that collagen fiber re-alignment may be a potential mechanism of preconditioning and merits further investigation. In particular, the conditions necessary for collagen fibers to re-orient away from the direction of loading and the dependency of collagen reorganization on its initial distribution must be examined.     

Quantification of muscle fiber strain during in vivo repetitive stretch-shortening cycles.

Muscles subjected to lengthening contractions exhibit evidence of subcellular disruption, arguably a result of fiber strain magnitude. Due to the difficulty associated with measuring fiber strains during lengthening contractions, fiber length estimates have been used to formulate relationships between the magnitude of injury and mechanical measures such as fiber strain. In such protocols, the series compliance is typically minimized by removing the distal tendon and/or preactivating the muscle. These in vitro and in situ experiments do not represent physiological contractions well where fiber strain and muscle strain may be disassociated; thus the mechanisms of in vivo muscle injury remain elusive. The purpose of this paper was to quantify fiber strains during lengthening contractions in vivo and assess the potential role of fiber strain in muscle injury following repetitive stretch-shortening cycles. Using intact New Zealand White rabbit dorsiflexors, fiber strain and joint torque were measured during 50 stretch-shortening cycles. We were able to show that fiber length changes are disassociated from muscle tendon unit length changes and that complex fiber dynamics during these cycles prevent easy estimates of fiber strains. In addition, fiber strains vary, depending on how they are defined, and vary from repetition to repetition, thereby further complicating the potential relationship between muscle injury and fiber strain. We conclude from this study that, during in vivo stretch-shortening cycles, the relationship between fiber strain and muscle injury is complex. This is due, in part, to temporal effects of repeated loading on fiber strain magnitude that may be explained by an increasing compliance of the contractile element as exercise progresses.     

Strain-related collagen gene expression in human osteoblast-like cells

The gene expression of cells in the musculoskeletal system, such as in bone, cartilage, ligament and tendon, is profoundly affected by mechanical loading. Previous studies have demonstrated that the expression of many genes, including collagen types I and III, are affected by mechanical strain in diverse cell types, such as human osteoblast-like SaOs-2 cells. However, whether the effect of mechanical loading on collagen gene expression is strain-related remains unclear. The goal of this study was to determine the relationship between mechanical strain and the gene expression of collagen types I and III in SaOs-2 cells. A Flexercell cellular mechanical loading system was used to subject SaOs-2 cells to equibiaxial cyclic tensile stress at a rate of 0.5 Hz with various strains of 5%, 7.5%, 10%, and 12.5% for 24 h. The relative amount of mRNA of both collagen I and collagen III increased at 5% strain compared with that of the control. As the strain increased, the relative amount of mRNA of collagen I remained stable at strain levels up to 12.5%. However, the mRNA for collagen III began to drop when the strain was greater than 5%, until a 10% strain was reached. From the application of a 10% strain through the maximum loading of a 12.5% strain, the relative amount of collagen III mRNA remained stable at amounts lower than that of the control. Thus, the gene expression of collagen types I and III responds differentially to mechanical strain at various magnitudes.     

Stress wave velocities in bovine patellar tendon.

The velocity of longitudinal stress waves in an elastic body is given by the square root of the ratio of its elastic modulus to its density. In tendinous and ligamentous tissue, the elastic modulus increases with strain and with strain rate. Therefore, it was postulated that stress wave velocity would also increase with increasing strain and strain rate. The purpose of this study was to determine the velocity of stress waves in tendinous tissue as a function of strain and to compare these values to those predicted using the elastic modulus derived from quasi-static testing. Five bovine patellar tendons were harvested and potted as bone-tendon-bone specimens. Quasi-static mechanical properties were determined in tension at a deformation rate of 100 mm/s. Impact loading was employed to determine wave velocity at various strain levels, achieved by preloading the tendon. Following impact, there was a measurable delay in force transmission across the specimen and this delay decreased with increasing tendon strain. The wave velocities at tendon strains of 0.0075, 0.015, and 0.0225 were determined to be 260 +/- 52 m/s, 360 +/- 71 m/s, and 461 +/- 94 m/s, respectively. These velocities were significantly (p < 0.01) faster than those predicted using elastic moduli derived from the quasi-static tests by 52, 45, and 41 percent, respectively. This study has documented that stress wave velocity in patellar tendon increases with increasing strain and is underestimated with a modulus estimated from quasi-static testing.     

In situ estimation of tendon material properties: Differences between muscles of the feline hindlimb

Recent experiments to characterize the short-range stiffness (SRS)–force relationship in several cat hindlimb muscles suggested that the there are differences in the tendon elastic moduli across muscles [Cui, L., Perreault, E.J., Maas, H., Sandercock, T.G., 2008. Modeling short-range stiffness of feline lower hindlimb muscles. J. Biomech. 41 (9), 1945–1952.]. Those conclusions were inferred from whole muscle experiments and a computational model of SRS. The present study sought to directly measure tendon elasticity, the material property most relevant to SRS, during physiological loading to confirm the previous modeling results. Measurements were made from the medial gastrocnemius (MG), tibialis anterior (TA) and extensor digitorum longus (EDL) muscles during loading. For the latter, the model indicated a substantially different elastic modulus than for MG and TA. For each muscle, the stress–strain relationship of the external tendon was measured in situ during the loading phase of isometric contractions conducted at optimum length. Young's moduli were assessed at equal strain levels (1%, 2% and 3%), as well as at peak strain. The stress–strain relationship was significantly different between EDL and MG/TA, but not between MG and TA. EDL had a more apparent toe region (i.e., lower Young's modulus at 1% strain), followed by a more rapid increase in the slope of the stress–strain curve (i.e., higher Young's modulus at 2% and 3% strain). Young's modulus at peak strain also was significantly higher in EDL compared to MG/TA, whereas no significant difference was found between MG and TA. These results indicate that during natural loading, tendon Young's moduli can vary considerably across muscles. This creates challenges to estimating muscle behavior in biomechanical models for which direct measures of tendon properties are not available.     

A finite element model predicts the mechanotransduction response of tendon cells to cyclic tensile loading

The importance of fluid-flow-induced shear stress and matrix-induced cell deformation in transmitting the global tendon load into a cellular mechanotransduction response is yet to be determined. A multiscale computational tendon model composed of both matrix and fluid phases was created to examine how global tendon loading may affect fluid-flow-induced shear stresses and membrane strains at the cellular level. The model was then used to develop a quantitative experiment to help understand the roles of membrane strains and fluid-induced shear stresses on the biological response of individual cells. The model was able to predict the global response of tendon to applied strain (stress, fluid exudation), as well as the associated cellular response of increased fluid-flow-induced shear stress with strain rate and matrix-induced cell deformation with strain amplitude. The model analysis, combined with the experimental results, demonstrated that both strain rate and strain amplitude are able to independently alter rat interstitial collagenase gene expression through increases in fluid-flow-induced shear stress and matrix-induced cell deformation, respectively.     

Regional stiffening with aging in tibialis anterior tendons of mice occurs independent of changes in collagen fibril morphology

The incidence of tendon degeneration and rupture increases with advancing age. The mechanisms underlying this increased risk remain unknown but may arise because of age-related changes in tendon mechanical properties and structure. Our purpose was to determine the effect of aging on tendon mechanical properties and collagen fibril morphology. Regional mechanical properties and collagen fibril characteristics were determined along the length of tibialis anterior (TA) tendons from adult (8- to 12-mo-old) and old (28- to 30-mo-old) mice. Tangent modulus of all regions along the tendons increased in old age, but the increase was substantially greater in the proximal region adjacent to the muscle than in the rest of the tendon. Overall end-to-end modulus increased with old age at maximum tendon strain (799 ± 157 vs. 1,419 ± 91 MPa) and at physiologically relevant strain (377 ± 137 vs. 798 ± 104 MPa). Despite the dramatic changes in tendon mechanical properties from adulthood to old age, collagen fibril morphology and packing fraction remained relatively constant in all tendon regions examined. Since tendon properties are influenced by their external loading environment, we also examined the effect of aging on TA muscle contractile properties. Maximum isometric force did not differ between the age groups. We conclude that TA tendons stiffen in a region-dependent manner throughout the life span, but the changes in mechanical properties are not accompanied by corresponding changes in collagen fibril morphology or force-generating capacity of the TA muscle.     

Mechanobiology of tendon

Tendons are able to respond to mechanical forces by altering their structure, composition, and mechanical properties--a process called tissue mechanical adaptation. The fact that mechanical adaptation is effected by cells in tendons is clearly understood; however, how cells sense mechanical forces and convert them into biochemical signals that ultimately lead to tendon adaptive physiological or pathological changes is not well understood. Mechanobiology is an interdisciplinary study that can enhance our understanding of mechanotransduction mechanisms at the tissue, cellular, and molecular levels. The purpose of this article is to provide an overview of tendon mechanobiology. The discussion begins with the mechanical forces acting on tendons in vivo, tendon structure and composition, and its mechanical properties. Then the tendon's response to exercise, disuse, and overuse are presented, followed by a discussion of tendon healing and the role of mechanical loading and fibroblast contraction in tissue healing. Next, mechanobiological responses of tendon fibroblasts to repetitive mechanical loading conditions are presented, and major cellular mechanotransduction mechanisms are briefly reviewed. Finally, future research directions in tendon mechanobiology research are discussed.     

How preconditioning affects the measurement of poro-viscoelastic mechanical properties in biological tissues

It is known that initial loading curves of soft biological tissues are substantially different from subsequent loadings. The later loading curves are generally used for assessing the mechanical properties of a tissue, and the first loading cycles, referred to as preconditioning, are omitted. However, slow viscoelastic phenomena related to fluid flow or collagen viscoelasticity are initiated during these first preconditioning loading cycles and may persist during the actual data collection. When these data are subsequently used for fitting of material properties, the viscoelastic phenomena that occurred during the initial cycles are not accounted for. The aim of the present study is to explore whether the above phenomena are significant for articular cartilage, by evaluating the effect of such time-dependent phenomena by means of computational modeling. Results show that under indentation, collagen viscoelasticity dominates the time-dependent behavior. Under UC, fluid-dependent effects are more important. Interestingly, viscoelastic and poroelastic effects may act in opposite directions and may cancel each other out in a stress–strain curve. Therefore, equilibrium may be apparent in a stress–strain relationship, even though internally the tissue is not in equilibrium. Also, the time-dependent effects of viscoelasticity and poroelasticity may reinforce each other, resulting in a sustained effect that lasts longer than suggested by their individual effects. Finally, the results illustrate that data collected from a mechanical test may depend on the preconditioning protocol. In conclusion, preconditioning influences the mechanical response of articular cartilage significantly and therefore cannot be neglected when determining the mechanical properties. To determine the full viscoelastic and poroelastic properties of articular cartilage requires fitting to both preconditioning and post-preconditioned loading cycles.     

Influence of altered geometry and material properties on tissue stress distribution under load in tendinopathic Achilles tendons – A subject-specific finite element analysis

Achilles tendon material properties and geometry are altered in Achilles tendinopathy. The purpose of this study was to determine the relative contributions of altered material properties and geometry to free Achilles tendon stress distribution during a sub-maximal contraction in tendinopathic relative to healthy tendons. Tendinopathic (n = 8) and healthy tendons (n = 8) were imaged at rest and during a sub-maximal voluntary isometric contraction using three-dimensional freehand ultrasound. Images were manually segmented and used to create subject-specific finite element models. The resting cross-sectional area of the free tendon was on average 31% greater for the tendinopathic compared to healthy tendons. Material properties for each tendon were determined using a numerical parameter optimisation approach that minimised the difference in experimentally measured longitudinal strain and the strain predicted by the finite element model under submaximal loading conditions for each tendon. The mean Young’s modulus for tendinopathic tendons was 53% lower than the corresponding control value. Finite element analyses revealed that tendinopathic tendons experience 24% less stress under the same submaximal external loading conditions compared to healthy tendons. The lower tendon stress in tendinopathy was due to a greater influence of tendon cross-sectional area, which alone reduced tendon stress by 30%, compared to a lower Young’s modulus, which alone increased tendon stress by 8%. These findings suggest that the greater tendon cross-sectional area observed in tendinopathy compensates for the substantially lower Young’s modulus, thereby protecting pathological tendon against excessive stress.     

Characterizing local collagen fiber re-alignment and crimp behavior throughout mechanical testing in a mature mouse supraspinatus tendon model

BackgroundCollagen fiber re-alignment and uncrimping are two postulated mechanisms of tendon structural response to load. Recent studies have examined structural changes in response to mechanical testing in a postnatal development mouse supraspinatus tendon model (SST), however, those changes in the mature mouse have not been characterized. The objective of this study was to characterize collagen fiber re-alignment and crimp behavior throughout mechanical testing in a mature mouse SST.Method of approachA tensile mechanical testing set-up integrated with a polarized light system was utilized for alignment and mechanical analysis. Local collagen fiber crimp frequency was quantified immediately following the designated loading protocol using a traditional tensile set up and a flash-freezing method. The effect of number of preconditioning cycles on collagen fiber re-alignment, crimp frequency and mechanical properties in midsubstance and insertion site locations were examined.ResultsDecreases in collagen fiber crimp frequency were identified at the toe-region of the mechanical test at both locations. The insertion site re-aligned throughout the entire test, while the midsubstance re-aligned during preconditioning and the test's linear-region. The insertion site demonstrated a more disorganized collagen fiber distribution, lower mechanical properties and a higher cross-sectional area compared to the midsubstance location.ConclusionsLocal collagen fiber re-alignment, crimp behavior and mechanical properties were characterized in a mature mouse SST model. The insertion site and midsubstance respond differently to mechanical load and have different mechanisms of structural response. Additionally, results support that collagen fiber crimp is a physiologic phenomenon that may explain the mechanical test toe-region.     

Region-specific mechanical properties of the human patella tendon.

The present study investigated the mechanical properties of tendon fascicles from the anterior and posterior human patellar tendon. Collagen fascicles from the anterior and posterior human patellar tendon in healthy young men (mean +/- SD, 29.0 +/- 4.6 yr, n = 6) were tested in a mechanical rig. A stereoscopic microscope equipped with a digital camera recorded elongation. The fascicles were preconditioned five cycles before the failure test based on pilot data on rat tendon fascicle. Human fascicle length increased with repeated cycles (P < 0.05); cycle 5 differed from cycle 1 (P < 0.05), but not cycles 2-4. Peak stress and yield stress were greater for anterior (76.0 +/- 9.5 and 56.6 +/- 10.4 MPa, respectively) than posterior fascicles (38.5 +/- 3.9 and 31.6 +/- 2.9 MPa, respectively), P < 0.05, while yield strain was similar (anterior 6.8 +/- 1.0%, posterior 8.7 +/- 1.4%). Tangent modulus was greater for the anterior (1,231 +/- 188 MPa) than the posterior (583 +/- 122 MPa) fascicles, P < 0.05. In conclusion, tendon fascicles from the anterior portion of the human patellar tendon in young men displayed considerably greater peak and yield stress and tangent modulus compared with the posterior portion of the tendon, indicating region-specific material properties.     

Age-related effect of static and cyclic loadings on the strain-force curve of the vastus lateralis tendon and aponeurosis

The objective of the present study was to investigate the age-related effects of submaximal static and cyclic loading on the mechanical properties of the vastus lateralis (VL) tendon and aponeurosis in vivo. Fourteen old and 12 young male subjects performed maximal voluntary isometric knee extensions (MVC) on a dynamometer before and after (a) a sustained isometric contraction at 25% MVC and (b) isokinetic contractions at 50% isokinetic MVC, both until task failure. The elongation of the VL tendon and aponeurosis was examined using ultrasonography. To calculate the resultant knee joint moment, the kinematics of the leg were recorded with eight cameras (120 Hz). The old adults displayed significantly lower maximal moments but higher strain values at any given tendon force from 400 N and up in all tested conditions. Neither of the loading protocols influenced the strain-force relationship of the VL tendon and aponeurosis in either the old or young adults. Consequently, the capacity of the tendon and aponeurosis to resist force remained unaffected in both groups. It can be concluded that in vivo tendons are capable of resisting long-lasting static (~4.6 min) or cyclic (~18.5 min) mechanical loading at the attained strain levels (4-5%) without significantly altering their mechanical properties regardless of age. This implies that as the muscle becomes unable to generate the required force due to fatigue, the loading of the tendon is terminated prior to provoking any significant changes in tendon mechanical properties.     

In vivo investigation of tendon responses to mechanical loading

Tendons transmit skeletal muscle forces to bone and are essential in all voluntary movement. In turn, movement appears to affect tendon properties, and in recent years considerable effort has been put into discovering how tendon tissue responds to mechanical stimuli in vivo. Months and years of mechanical loading can influence the gross morphology of tendon, seen as an increase tendon cross sectional area (CSA). Similarly, tendon stiffness appears to be affected by weeks to months of loading. Increased stiffness can relate to changes in CSA and/or tendon material properties (modulus), though the relative contribution of these parameters is largely unclear. The possible mechanisms behind alterations in tendon material properties include changes in collagen fibril morphology and levels of cross-linking between collagen molecules. Furthermore, increased levels of collagen synthesis and expression are seen as a response to acute exercise and training, and may be a central parameter in tendon adaptation to loading. There are indications that this collagen-induction relates to the auto-/paracrine action of collagen-stimulating growth factors, such as TGFβ-1 and IGF-I, which are expressed in response to mechanical stimuli.