Calcaneal Tendon Regions Exhibit Different MMP-2 Activation After Vertical Jumping and Treadmill Running

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Therapeutic potential of mesenchymal stem cells to treat Achilles tendon injuries

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Tenoplastia experimental do calcâneo em cães com peritônio bovino conservado em glicerina

No presente estudo, avaliou-se a eficácia do emprego do peritônio bovino, conservado em glicerina a 98%, no reparo de lesões induzidas no tendão calcâneo (TC) de cães, quando um fragmento de aproximadamente 1cm do TC foi excisado e o espaço resultante preenchido por um fragmento de peritônio. Foram utilizados 21 cães, pesando entre 10 e 15kg, divididos em 7 grupos de 3, sacrificados aos 02, 07, 15, 30, 60, 90 e 120 dias de pós-operatório. Analisaram-se os aspectos clínico-cirúrgicos referentes à recuperação funcional motora, bem como, a integração do peritônio com o tecido tendíneo mediante avaliação macroscópica, por microscopia óptica e por microscopia eletrônica de varredura. Clinicamente, verificou-se que, por volta do 55º dia de pós-operatório, os animais já apresentavam deambulação normal e que o neotendão apresentou resistência suficiente para suportar o estresse normalmente aplicado ao TC. Microscopicamente, o peritônio implantado esteve presente em todos os períodos de observação. Proliferação fibroblástica e neoformação vascular foram observadas de forma incipiente no segundo dia; entretanto, no sétimo dia de pós-operatório, esta condição foi exacerbada. Com a evolução, as fibras de peritônio tendiam a se dissociar, entrando em estreita associação com fibras conjuntivas, fibroblastos e colágeno. Aos 30, 60, 90 e 120 dias de pós-operatório, notava-se maior presença de colágeno que se tornava cada vez mais organizado. Concluiu-se que o peritônio estimulou uma rápida deposição de tecido conjuntivo com mínima reação inflamatória, sendo incorporado ao tecido cicatricial e servindo como alicerce para o desenvolvimento de um novo tecido, restabelecendo assim a estrutura do tendão.

O bloqueio da atividade nitrérgica no tendão de ratos submetidos à tenotomia com sutura acelera a regeneração muscular

A atrofia é uma resposta imediata do músculo em situações de tensão e carga reduzida e caracteriza-se por mudanças morfológicas, aumento da proteólise muscular, perda de massa e redução da área da fibra que estão implicadas em déficits funcionais, afetando assim a qualidade de vida dos indivíduos. Rupturas tendíneas ocasionam atrofia muscular devido à intrínseca relação funcional existente entre ambas as estruturas, músculos-tendões. Considerando a injúria tendínea, trabalho prévio do nosso grupo identificou que a inibição da síntese de óxido nítrico localmente a injúria acelerou a recuperação histológica no tendão e a melhora funcional em animais tenotomizados. Desta forma, a proposta do trabalho é avaliar os efeitos da inibição nitrérgica local no tendão em relação ao padrão de regeneração muscular. Portanto, para gerar atrofia muscular esquelética, o trabalho utiliza o modelo experimental de ruptura do tendão calcâneo com posterior sutura. Os grupos foram divididos em controle, ruptura, ruptura+veículo (Salina 0,9%) e ruptura+L-nitro-arginina-metil-éster (L-NAME, 5mM). As amostras foram coletadas 14 e 21 dias seguintes ao procedimento cirúrgico experimental. Objetivando avaliar a dosagem de proteínas, o método de Bradford foi utilizado. As amostras também foram reservadas para processamento histológico qualitativo e quantitativo da área da fibra muscular e presença de lesões de núcleo central. Assim como no trabalho prévio de nosso grupo, acreditamos que a ação da droga restringiu-se ao local, pois não ocasionou fortes influências em relação ao peso corporal dos animais, que foi medido nos dias 0, 7, 14 e 21. O grupo tratado com L-NAME apresentou diminuição significativa no número de lesões de núcleo central no 14º dia pós-operatório e aumento nos níveis de proteína e área da fibra no 21º dia. Em conjunto, nossos resultados sugerem que houve efeito benéfico da inibição local da NOS após a ruptura com relação à atenuação da atrofia, contribuindo para acelerar a regeneração muscular.

Efeito da aplicação do ultrassom terapêutico durante 4 e 5 minutos por área do transdutor no processo de reparação de tendão de ratos

O objetivo deste estudo foi avaliar o efeito dos tempos de aplicação 3, 4 e 5 minutos por ERA do ultrassom terapêutico (UST) na organização das fibras de colágeno em lesão do tendão do calcâneo de ratos. Foram utilizados quarenta ratos machos Wistar, dos quais 32 sofreram tenotomia total do tendão do calcâneo e foram divididos em 5 grupos: GC, sem tenotomia e tratamento; GT, com tenotomia e sem tratamento; UST3, UST4 e UST5 submetidos à tenotomia e tratados com UST nos tempos de 3, 4 e 5 minutos por área de radiação efetiva respectivamente. Os animais foram submetidos à primeira aplicação do UST foi 24 horas após a cirurgia de tenotomia. A irradiação ultrassônica foi aplicada com os seguintes parâmetros: 1 MHz, modo pulsado com 20% do ciclo de trabalho (2 ms de emissão / 8 ms de intervalo), frequência de 100 Hz, 0,5 W / cm² de intensidade e ERA de 0,5 cm². A aplicação foi realizada 1x/dia. Os animais foram sacrificados após a 10ª sessão de tratamento, no 12º dia pós-operatório. Os tendões foram retirados cirurgicamente para análise da organização das fibras colágenas através do método de birrefringência (retardo óptico - OR). As fibras colágenas mostraram melhor agregação e organização no grupo UST3, UST4 e UST5 quando comparado ao GT (p<0.05) e o UST5 apresentou melhor resposta na comparação intergrupos. Conclui-se que o UST, aplicado no tempo de 5 minutos por área de radiação efetiva, apresentou a melhor dose-resposta quanto à organização das fibras colágenas no reparo tecidual de tendões de ratos

Long-term follow-up of flexor digitorum longus transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction

Flexor digitorum longus transfer and medial displacement alcaneal osteotomy is a wellrecognised form of treatment or stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flatfoot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (SD 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Incidental walking activity is sufficient to induce time-dependent conditioning of the Achilles tendon

The Achilles tendon has been seen to exhibit time-dependent conditioning when isometric muscle actions were of a prolonged duration, compared to those involved in dynamic activities, such as walking. Since, the effect of short duration muscle activation associated with dynamic activities is yet to be established, the present study aimed to investigate the effect of incidental walking activity on Achilles tendon diametral strain. Eleven healthy male participants refrained from physical activity in excess of the walking required to carry out necessary daily tasks and wore an activity monitor during the 24 h study period. Achilles tendon diametral strain, 2 cm proximal to the calcaneal insertion, was determined from sagittal sonograms. Baseline sonographic examinations were conducted at ∼08:00 h followed by replicate examinations at 12 and 24 h. Walking activity was measured as either present (1) or absent (0) and a linear weighting function was applied to account for the proximity of walking activity to tendon examination time. Over the course of the day the median (min, max) Achilles tendon diametral strain was −11.4 (4.5, −25.4)%. A statistically significant relationship was evident between walking activity and diametral strain (P < 0.01) and this relationship improved when walking activity was temporally weighted (AIC 131 to 126). The results demonstrate that the short yet repetitive loads generated during activities of daily living, such as walking, are sufficient to induce appreciable time-dependant conditioning of the Achilles tendon. Implications arise for the in vivo measurement of Achilles tendon properties and the rehabilitation of tendinopathy.

Overweight and obesity alters the cumulative transverse strain in the Achilles tendon immediately following exercise

This research evaluated the effect of obesity on the acute cumulative transverse strain of the Achilles tendon in response to exercise. Twenty healthy adult males were categorized into ‘low normal-weight’ (BMI <23 kg m−2) and ‘overweight’ (BMI >27.5 kg m−2) groups based on intermediate cut-off points recommended by the World Health Organization. Longitudinal sonograms of the right Achilles tendon were acquired immediately prior and following weight-bearing ankle exercises. Achilles tendon thickness was measured 20-mm proximal to the calcaneal insertion and transverse tendon strain was calculated as the natural log of the ratio of post- to pre-exercise tendon thickness. The Achilles tendon was thicker in the overweight group both prior to (t18 = −2.91, P = 0.009) and following (t18 = −4.87, P < 0.001) exercise. The acute transverse strain response of the Achilles tendon in the overweight group (−10.7 ± 2.5%), however, was almost half that of the ‘low normal-weight’ (−19.5 ± 7.4%) group (t18 = −3.56, P = 0.004). These findings suggest that obesity is associated with structural changes in tendon that impairs intra-tendinous fluid movement in response to load and provides new insights into the link between tendon pathology and overweight and obesity.

Ankle joint pressure changes in a pes cavovarus model after lateralizing calcaneal osteotomies

Tendon transfers and calcaneal osteotomies are commonly used to treat symptoms related to medial ankle arthrosis in fixed pes cavovarus. However, the relative effect of these osteotomies in terms of lateralizing the ground contact point of the hindfoot and redistributing ankle joint contact stresses are unknown.

Anisotropy of spin relaxation of water protons in cartilage and tendon

Transverse spin relaxation rates of water protons in articular cartilage and tendon depend on the orientation of the tissue relative to the applied static magnetic field. This complicates the interpretation of magnetic resonance images of these tissues. At the same time, relaxation data can provide information about their organisation and microstructure. We present a theoretical analysis of the anisotropy of spin relaxation of water protons observed in fully hydrated cartilage. We demonstrate that the anisotropy of transverse relaxation is due almost entirely to intramolecular dipolar coupling modulated by a specific mode of slow molecular motion: the diffusion of water molecules in the hydration shell of a collagen fibre around the fibre, such that the molecular director remains perpendicular to the fibre. The theoretical anisotropy arising from this mechanism follows the “magic-angle” dependence observed in magnetic-resonance measurements of cartilage and tendon and is in good agreement with the available experimental results. We discuss the implications of the theoretical findings for MRI of ordered collagenous tissues.

Eccentric calf muscle exercise produces a greater acute reduction in Achilles tendon thickness than concentric exercise

Objective: To investigate the acute effects of isolated eccentric and concentric calf muscle exercise on Achilles tendon sagittal thickness. ---------- Design: Within-subject, counterbalanced, mixed design. ---------- Setting: Institutional. ---------- Participants: 11 healthy, recreationally active male adults. ---------- Interventions: Participants performed an exercise protocol, which involved isolated eccentric loading of the Achilles tendon of a single limb and isolated concentric loading of the contralateral, both with the addition of 20% bodyweight. ---------- Main outcome measurements: Sagittal sonograms were acquired prior to, immediately following and 3, 6, 12 and 24 h after exercise. Tendon thickness was measured 2 cm proximal to the superior aspect of the calcaneus. ---------- Results: Both loading conditions resulted in an immediate decrease in normalised Achilles tendon thickness. Eccentric loading induced a significantly greater decrease than concentric loading despite a similar impulse (−0.21 vs −0.05, p<0.05). Post-exercise, eccentrically loaded tendons recovered exponentially, with a recovery time constant of 2.5 h. The same exponential function did not adequately model changes in tendon thickness resulting from concentric loading. Even so, recovery pathways subsequent to the 3 h time point were comparable. Regardless of the exercise protocol, full tendon thickness recovery was not observed until 24 h. ---------- Conclusions: Eccentric loading invokes a greater reduction in Achilles tendon thickness immediately after exercise but appears to recover fully in a similar time frame to concentric loading.

Conditioning of the Achilles tendon via ankle exercise improves correlations between sonographic measures of tendon thickness and body anthropometry

Although conditioning is routinely used in mechanical tests of tendon in vitro, previous in vivo research evaluating the influence of body anthropometry on Achilles tendon thickness has not considered its potential effects on tendon structure. This study evaluated the relationship between Achilles tendon thickness and body anthropometry in healthy adults both before and after resistive ankle plantarflexion exercise. A convenience sample of 30 healthy male adults underwent sonographic examination of the Achilles tendon in addition to standard anthropometric measures of stature and body weight. A 10-5 MHz linear array transducer was used to acquire longitudinal sonograms of the Achilles tendon, 20 mm proximal to the tendon insertion. Participants then completed a series (90-100 repetitions) of conditioning exercises against an effective resistance between 100% and 150% body weight. Longitudinal sonograms were repeated immediately on completion of the exercise intervention, and anteroposterior Achilles tendon thickness was determined. Achilles tendon thickness was significantly reduced immediately following conditioning exercise (t = 9.71, P < 0.001), resulting in an average transverse strain of -18.8%. In contrast to preexercise measures, Achilles tendon thickness was significantly correlated with body weight (r = 0.72, P < 0.001) and to a lesser extent height (r = 0.45, P < 0.01) and body mass index (r = 0.63, P < 0.001) after exercise. Conditioning of the Achilles tendon via resistive ankle exercises induces alterations in tendon structure that substantially improve correlations between Achilles tendon thickness and body anthropometry. It is recommended that conditioning exercises, which standardize the load history of tendon, are employed before measurements of sonographic tendon thickness in vivo.

Achilles tendinopathy has an aberrant strain response to eccentric exercise

Purpose: Eccentric exercise has become the treatment of choice for Achilles tendinopathy. However, little is known about the acute response of tendons to eccentric exercise or the mechanisms underlying its clinical benefit. This research evaluated the sonographic characteristics and acute anteroposterior (AP) strain response of control (healthy), asymptomatic, and symptomatic Achilles tendons to eccentric exercise. Methods: Eleven male adults with unilateral midportion Achilles tendinopathy and nine control male adults without tendinopathy participated in the research. Sagittal sonograms of the Achilles tendon were acquired immediately before and after completion of a common eccentric rehabilitation exercise protocol and again 24 h later. Tendon thickness, echogenicity, and AP strain were determined 40 mm proximal to the calcaneal insertion. Results: Compared with the control tendon, both the asymptomatic and symptomatic tendons were thicker (P < 0.05) and hypoechoic (P < 0.05) at baseline. All tendons decreased in thickness immediately after eccentric exercise (P < 0.05). The symptomatic tendon was characterized by a significantly lower AP strain response to eccentric exercise compared with both the asymptomatic and control tendons (P < 0.05). AP strains did not differ in the control and asymptomatic tendons. For all tendons, preexercise thickness was restored 24 h after exercise completion. Conclusions: These observations support the concept that Achilles tendinopathy is a bilateral or systemic process and structural changes associated with symptomatic tendinopathy alter fluid movement within the tendon matrix. Altered fluid movement may disrupt remodeling and homeostatic processes and represents a plausible mechanism underlying the progression of tendinopathy.

Measuring mechanical properties of tendon in vivo

Introduction: Understanding the mechanical properties of tendon is an important step to guiding the process of improving athletic performance, predicting injury and treating tendinopathies. The speed of sound in a medium is governed by the bulk modulus and density for fluids and isotropic materials. However, for tendon,which is a structural composite of fluid and collagen, there is some anisotropy requiring an adjustment for Poisson’s ratio. In this paper, these relationships are explored and modelled using data collected, in vivo, on human Achilles tendon. Estimates for elastic modulus and hysteresis based on speed of sound data are then compared against published values from in vitro mechanical tests. Methods: Measurements using clinical ultrasound imaging, inverse dynamics and acoustic transmission techniques were used to determine dimensions, loading conditions and longitudinal speed of sound for the Achilles tendon during a series of isometric plantar flexion exercises against body weight. Upper and lower bounds for speed of sound versus tensile stress in the tendon were then modelled and estimates derived for elastic modulus and hysteresis. Results: Axial speed of sound varied between 1850 to 2090 m.s−1 with a non-linear, asymptotic dependency on the level of tensile stress in the tendon 5–35 MPa. Estimates derived for the elastic modulus ranged between 1–2 GPa. Hysteresis derived from models of the stress-strain relationship, ranged from 3–11%. These values agree closely with those previously reported from direct measurements obtained via in vitro mechanical tensile tests on major weight bearing tendons. Discussion: There is sufficiently good agreement between these indirect (speed of sound derived) and direct (mechanical tensile test derived) measures of tendon mechanical properties to validate the use of this non-invasive acoustic transmission technique. This non-invasive method is suitable for monitoring changes in tendon properties as predictors of athletic performance, injury or therapeutic progression.

Load bearing improves the limits of agreement for repeated in vivo measures of the speed of sound in human Achilles tendon

Axial acoustic wave propagation has been widely used in evaluating the mechanical properties of human bone in vivo. However, application of this technique to monitor soft tissues, such as tendon, has received comparatively little scientific attention. Laboratory-based research has established that axial acoustic wave transmission is not only related to the physical properties of equine tendon but is also proportional to tensile load to which it is exposed (Miles et al., 1996; Pourcelot et al., 2005). The reproducibility of the technique for in vivo measurements in human tendon, however, has not been established. The aim of this study was to evaluate the limits of agreement for repeated measures of the speed of sound (SoS) in human Achilles tendon in vivo. Methods: A custom built ultrasound device, consisting of an A-mode 1MHz emitter and two regularly spaced receivers, was used to measure the SoS in the mid-portion of the Achilles tendon in ten healthy males and ten females (mean age: 33.8 years, range 23-56 yrs; height: 1.73±0.08 m; weight: 68.4±15.3 kg). The emitter and receivers were held at fixed positions by a polyethylene frame and maintained in close contact with the skin overlying the tendon by means of elasticated straps. Repeated SoS measurements were taken with the subject prone (non-weightbearing and relaxed Achilles tendon) and during quiet bipedal and unipedal stance. In each instance, the device was detached and repositioned prior to measurement. Results: Limits of agreement for repeated SoS measures during non-weightbearing and bipedal and unipedal stance were ±53, ±28 and ±21 m/s, respectively. The average SoS in the non-weightbearing Achilles tendon was 1804±198 m/s. There was a significant increase in the average SoS during bilateral (2122±135 m/s) (P < 0.05) and unilateral (2221±79 m/s) stance (P < 0.05). Conclusions: Repeated SoS measures in human Achilles tendon were more reliable during stance than under non-weightbearing conditions. These findings are consistent with previous research in equine tendon in which lower variability in SoS was observed with increasing tensile load (Crevier-Denoix et al, 2009). Since the limits of agreement for Achilles tendon SoS are nearly 5% of the changes previously observed during walking and therapeutic heel raise exercises, acoustic wave transmission provides a promising new non-invasive method for determining tendon properties during sports and rehabilitation related activities.