The human myotendinous junction: an ultrastructural and 3D analysis study

Dilemma in the Treatment of Sports Injuries in Athletes: Tendon Overuse, Muscle Strain, and Tendon Rupture

Injuries to the musculoskeletal system are frequent in elite sports and they are detrimental to athletic performance. This can be due to, for example, (1) overuse disorders of tendon (tendinopathy) that not only lower the training efficiency but also, in many cases, are career-ending for the athlete due to pain; (2) acute muscle strain injury that both causes prolonged absence from competition and results in many re-injuries; or (3) tendon rupture that, apart from a very long rehabilitation period, will also result in many athletes never resuming their original high level of competitive sports. For all three injury examples, several evidence-based prevention programs and treatments are available, and yet the incidence of these injuries remains high and single treatments often provide only partial recovery. In this paper, we highlight the current treatments of these three conditions and focus on the unsolved dilemmas that exist in these sports injuries.

Fibre type differences in the organisation of mononuclear cells and myonuclei at the tips of human myofibres

The myotendinous junction (MTJ) is a weak link in the musculoskeletal system. Here, we isolated the tips of single myofibres from healthy (non-injured) human hamstring muscles for confocal microscopy (n=6) and undertook RNAscope in situ hybridisation (n=6) to gain insight into the profiles of cells and myonuclei in this region, in a fibre type manner. A marked presence of mononuclear cells was observed coating the myofibre tips (confirmed by serial block face scanning electron microscopy and cryosection immunofluorescence), with higher numbers for type I (median 29; range 16-63) than type II (16; 9-23) myofibres (P<0.05). The number of these cells expressing COL22A1 was comparable between fibre types. Myonuclear number and density gradually increased from the myofibre proper towards the tip for both fibre types (P<0.05). COL22A1 was expressed by similar proportions of myonuclei in type I (median 26%; range 13-56) and type II (19%; 3-67) myofibre tips. 70% of the COL22A1-positive nuclei in the MTJ region were myonuclei, and the remaining 30% were MTJ cells. This insight refines our fundamental understanding of the human MTJ at the cell and structural levels.

The Structure, Function, and Adaptation of Lower-Limb Aponeuroses: Implications for Myo-Aponeurotic Injury

The aponeurosis is a large fibrous connective tissue structure within and surrounding skeletal muscle and is a critical component of the muscle-tendon unit (MTU). Due to the lack of consensus on terminology and the heterogeneous nature of the aponeurosis between MTUs, there are several questions that remain unanswered. For example, the aponeurosis is often conflated with the free tendon rather than being considered an independent structure. This has subsequent implications when interpreting data regarding the structure, function, and adaptation of the aponeuroses from these studies. In recent years, a body of work has emerged to suggest that acute injury to the myo-aponeurotic complex may have an impact on return-to-sport timeframes and reinjury rates. Therefore, the purpose of this review is to provide a more detailed understanding of the morphology and mechanical behaviour common to all aponeuroses, as well as the unique characteristics of specific lower-limb aponeuroses that are commonly injured. This review provides the practitioner with a current understanding of the mechanical, material, and adaptive properties of lower limb aponeuroses and suggests directions for future research related to the myo-aponeurotic complex.

3D Printing of a Biomimetic Myotendinous Junction Assisted by Artificial Intelligence

The myotendinous junction (MTJ) facilitates force transmission between muscle and tendon to produce joint movement. The complex microarchitecture and regional mechanical heterogeneity of the myotendinous junction pose major challenges in creating this interface in vitro. Engineering this junction in vitro is challenging due to substantial fabrication difficulties in creating scaffolds with intricate microarchitecture and stiffness heterogeneity to mimic the native muscle-tendon interface. To address the current challenges in creating the MTJ in vitro, digital light processing (DLP)-based 3D printing was used to fabricate poly(glycerol sebacate)acrylate (PGSA)-based muscle-tendon scaffolds with physiologically informed microstructure and mechanical properties. Local mechanical properties in various regions of the scaffold were tuned by adjusting the exposure time and light intensity used during the continuous DLP-based 3D printing process to match the mechanical properties present in distinct regions of native muscle-tendon tissue using printing parameters defined by an artificial intelligence-trained algorithm. To evaluate how the presence of zonal stiffness regions can affect the phenotype of a 3D-printed MTJ in vitro model, three 3D-printed PGSA-based scaffold conditions were investigated: (1) a scaffold with muscle-informed mechanical properties in its entirety without zonal stiffness regions, (2) a scaffold with one end possessing native muscle stiffness and the other end possessing native tendon stiffness, and (3) a scaffold with three distinct regions whose stiffness values correspond to those of muscle on one end of the scaffold, MTJ in the middle junction of the scaffold, and tendon on the other end of the scaffold. The scaffold containing regional mechanical heterogeneity most similar to the native MTJ (condition 3) was found to enhance the expression of MTJ-related markers compared to those without the presence of zonal stiffness regions. Overall, the DLP-based 3D printing platform and biomaterial system developed in this study could serve as a useful tool for mimicking the complexity of the native MTJ, which possesses inherent geometric and mechanical heterogeneity.

Return to Sport, Reinjury Rate, and Tissue Changes after Muscle Strain Injury: A Narrative Review

A major challenge in sports medicine is to facilitate the fastest possible recovery from injury without increasing the risk of subsequent reruptures, and thus effective rehabilitation programs should balance between these two factors. The present review focuses on examining the role of different resistance training interventions in rehabilitation of acute muscle strain in the time frame from injury until return to sport (RTS), the rate of reinjuries, and tissue changes after injury. Randomized, controlled trials dealing with a component of resistance training in their rehabilitation protocols, as well as observational studies on tissue morphology and tissue changes as a result to muscle strain injuries, were included. The mean time for RTS varied from 15 to 86 days between studies (n = 8), and the mean rate of reinjury spanned from 0 to 70%. Eccentric resistance training at long muscle length and rapid introduction to rehabilitation postinjury led to significant improvement regarding RTS, and core-stabilizing exercises as well as implementing an individualized algorithm for rehabilitation seem to reduce the risk of reinjury in studies with a high rerupture rate. Independent of the rehabilitation program, structural changes appear to persist for a long time, if not permanently, after a strain injury.

Engineering interfacial tissues: The myotendinous junction

The myotendinous junction (MTJ) is the interface connecting skeletal muscle and tendon tissues. This specialized region represents the bridge that facilitates the transmission of contractile forces from muscle to tendon, and ultimately the skeletal system for the creation of movement. MTJs are, therefore, subject to high stress concentrations, rendering them susceptible to severe, life-altering injuries. Despite the scarcity of knowledge obtained from MTJ formation during embryogenesis, several attempts have been made to engineer this complex interfacial tissue. These attempts, however, fail to achieve the level of maturity and mechanical complexity required for in vivo transplantation. This review summarizes the strategies taken to engineer the MTJ, with an emphasis on how transitioning from static to mechanically inducive dynamic cultures may assist in achieving myotendinous maturity.

An engineered in vitro model of the human myotendinous junction

The myotendinous junction (MTJ) is a vulnerable region at the interface of skeletal muscle and tendon that forms an integrated mechanical unit. This study presents a technique for the spatially restrictive co-culture of human embryonic stem cell (hESC)-derived skeletal myocytes and primary tenocytes for two-dimensional modeling of the MTJ. Micropatterned lanes of extracellular matrix and a 2-well culture chamber define the initial regions of occupation. On day 1, both lines occupy less than 20 % of the initially vacant interstitial zone, referred to henceforth as the junction. Myocyte-tenocyte interdigitations are observed by day 7. Immunocytochemistry reveals enhanced organization and alignment of patterned myocyte and tenocyte features, as well as differential expression of multiple MTJ markers. On day 24, electrically stimulated junction myocytes demonstrate negative contractile strains, while positive tensile strains are exhibited by mechanically passive tenocytes at the junction. Unpatterned tenocytes distal to the junction experience significantly decreased strains in comparison to cells at the interface. Unpatterned myocytes have impaired organization and uncoordinated contractile behavior. These findings suggest that this platform is capable of inducing myocyte-tenocyte junction formation and mechanical coupling similar to the native MTJ, showing transduction of force across the cell-cell interface. STATEMENT OF SIGNIFICANCE: The myotendinous junction (MTJ) is an integrated structure that transduces force across the muscle-tendon boundary, making the region vulnerable to strain injury. Despite the clinical relevance, previous in vitro models of the MTJ lack the structure and mechanical accuracy of the native tissue and have difficulty transmitting force across the cell-cell interface. This study demonstrates an in vitro model of the MTJ, using spatially restrictive cues to inform human myocyte-tenocyte interactions and architecture. The model expressed MTJ markers and developed anisotropic myocyte-tenocyte integrations that resemble the native tissue and allow for force transduction from contracting myocytes to passive tenocyte regions. As such, this study presents a system capable of investigating development, injury, and pathology in the human MTJ.

Biceps femoris long head muscle and aponeurosis geometry in males with and without a history of hamstring strain injury

OBJECTIVES

Hamstring strain injuries (HSIs) commonly affect the proximal biceps femoris long head (BFlh) musculotendinous junction. Biomechanical modeling suggests narrow proximal BFlh aponeuroses and large muscle-to-aponeurosis width ratios increase localized tissue strains and presumably risk of HSI. This study aimed to determine if BFlh muscle and proximal aponeurosis geometry differed between limbs with and without a history of HSI.

METHODS

Twenty-six recreationally active males with (n = 13) and without (n = 13) a history of unilateral HSI in the last 24 months underwent magnetic resonance imaging of both thighs. BFlh muscle and proximal aponeurosis cross-sectional areas, length, volume, and interface area between muscle and aponeurosis were extracted. Previously injured limbs were compared to uninjured contralateral and control limbs for discrete variables and ratios, and along the relative length of tissues using statistical parametric mapping.

RESULTS

Previously injured limbs displayed significantly smaller muscle-to-aponeurosis volume ratios (p = 0.029, Wilcoxon effect size (ES) = 0.43) and larger proximal BFlh aponeurosis volumes (p = 0.019, ES = 0.46) than control limbs with no history of HSI. No significant differences were found between previously injured and uninjured contralateral limbs for any outcome measure (p = 0.216-1.000, ES = 0.01-0.36).

CONCLUSIONS

Aponeurosis geometry differed between limbs with and without a history of HSI. The significantly larger BFlh proximal aponeuroses and smaller muscle-to-aponeurosis volume ratios in previously injured limbs could alter the strain experienced in muscle adjacent to the musculotendinous junction during active lengthening. Future research is required to determine if geometric differences influence the risk of re-injury and whether they can be altered via targeted training.

A Comprehensive Review of Muscle-Tendon Junction: Structure, Function, Injury and Repair

The muscle-tendon junction (MTJ) is a highly specific tissue interface where the muscle's fascia intersects with the extracellular matrix of the tendon. The MTJ functions as the particular structure facilitating the transmission of force from contractive muscle fibers to the skeletal system, enabling movement. Considering that the MTJ is continuously exposed to constant mechanical forces during physical activity, it is susceptible to injuries. Ruptures at the MTJ often accompany damage to both tendon and muscle tissues. In this review, we attempt to provide a precise definition of the MTJ, describe its subtle structure in detail, and introduce therapeutic approaches related to MTJ tissue engineering. We hope that our detailed illustration of the MTJ and summary of the representative research achievements will help researchers gain a deeper understanding of the MTJ and inspire fresh insights and breakthroughs for future research.

Traumatic muscle injury

Traumatic muscle injury represents a collection of skeletal muscle pathologies caused by trauma to the muscle tissue and is defined as damage to the muscle tissue that can result in a functional deficit. Traumatic muscle injury can affect people across the lifespan and can result from high stresses and strains to skeletal muscle tissue, often due to muscle activation while the muscle is lengthening, resulting in indirect and non-contact muscle injuries (strains or ruptures), or from external impact, resulting in direct muscle injuries (contusion or laceration). At a microscopic level, muscle fibres can repair focal damage but must be completely regenerated after full myofibre necrosis. The diagnosis of muscle injury is based on patient history and physical examination. Imaging may be indicated to eliminate differential diagnoses. The management of muscle injury has changed within the past 5 years from initial rest, immobilization and (over)protection to early activation and progressive loading using an active approach. One challenge of muscle injury management is that numerous medical treatment options, such as medications and injections, are often used or proposed to try to accelerate muscle recovery despite very limited efficacy evidence. Another challenge is the prevention of muscle injury owing to the multifactorial and complex nature of this injury.

A Case Report on Myotendinous Junction

Myotendinous junction is the transition zone between the muscle and its tendon. Hence, it is subject to immense stress within the muscle. In this study, it is found that muscles having a greater tensile have a more arranged myotendinous junction compared to muscles with lesser tensile strength. Cadaveric specimens - plantaris, gastrocnemius, and soleus have been histologically studied to study the same.

Force transmission and interactions between synergistic muscles

The classical view of muscles as independent motors has been challenged over the past decades. An alternative view has emerged in which muscles are not isolated but embedded in a three-dimensional connective tissue network that links them to adjacent muscles and other non-muscular structures in the body. Animal studies showing that the forces measured at the distal and proximal ends of a muscle are not equal have provided undisputable evidence that these connective tissue linkages are strong enough to serve as an extra pathway for muscular force transmission. In this historical review, we first introduce the terminology and anatomy related to these pathways of muscle force transmission and provide a definition for the term epimuscular force transmission. We then focus on important experimental evidence indicating mechanical interactions between synergistic muscles that may affect force transmission and/or influence the muscles' force generating capacity. We illustrate that there may exist different expressions of the highly relevant force-length properties depending on whether the force is measured at the proximal or distal tendon and depending on the dynamics of surrounding structures. Changes in length, activation level or disruption of the connective tissue of neighboring muscles, can affect how muscles interact and produce force on the skeleton. While most direct evidence is from animal experiments, studies on humans also suggest functional implications of the connective tissues surrounding muscles. These implications may explain how distant segments, which are not part of the same joint system, affect force generation at a given joint, and, in clinical conditions, explain observations from tendon transfer surgeries, where a muscle transferred to act as an antagonist continues to produce agonistic moments.

Model of calf muscle tear during a simulated eccentric contraction, comparison between ex-vivo experiments and discrete element model

The tearing of the muscle-tendon complex (MTC) is one of the common sports-related injuries. A better understanding of the mechanisms of rupture and its location could help clinicians improve the way they manage the rehabilitation period of patients. A new numerical approach using the discrete element method (DEM) may be an appropriate approach, as it considers the architecture and the complex behavior of the MTC. The aims of this study were therefore: first, to model and investigate the mechanical elongation response of the MTC until rupture with muscular activation. Secondly, to compare results with experimental data, ex vivo tensile tests until rupture were done on human cadavers {triceps surae muscle + Achilles tendon}. Force/displacement curves and patterns of rupture were analyzed. A numerical model of the MTC was completed in DEM. In both numerical and experimental data, rupture appeared at the myotendinous junction (MTJ). Moreover, force/displacement curves and global rupture strain were in agreement between both studies. The order of magnitude of rupture force was close between numerical (858 N for passive rupture and 996 N-1032 N for rupture with muscular activation) and experimental tests (622 N ± 273 N) as for the displacement of the beginning of rupture (numerical: 28-29 mm, experimental: 31.9 mm ± 3.6 mm). These differences could be explained by choices of DEM model and mechanical properties of MTC's components or their rupture strain values. Here we show that he MTC was broken by fibers' delamination at the distal MTJ and by tendon disinsertion at the proximal MTJ in agreement with experimental data and literature.

Larger interface area at the human myotendinous junction in type 1 compared with type 2 muscle fibers

The myotendinous junction (MTJ) is structurally specialized to transmit force. The highly folded muscle membrane at the MTJ increases the contact area between muscle and tendon and potentially the load tolerance of the MTJ. Muscles with a high content of type II fibers are more often subject to strain injury compared with muscles with type I fibers. It is hypothesized that this is explained by a smaller interface area of MTJ in type II compared with type I muscle fibers. The aim was to investigate by confocal microscopy whether there is difference in the surface area at the MTJ between type I and II muscle fibers. Individual muscle fibers with an intact MTJ were isolated by microscopic dissection in samples from human semitendinosus, and they were labeled with antibodies against collagen XXII (indicating MTJ) and type I myosin (MHCI). Using a spinning disc confocal microscope, the MTJ from each fiber was scanned and subsequently reconstructed to a 3D-model. The interface area between muscle and tendon was calculated in type I and II fibers from these reconstructions. The MTJ was analyzed in 314 muscle fibers. Type I muscle fibers had a 22% larger MTJ interface area compared with type II fibers (p < 0.05), also when the area was normalized to fiber diameter. By the new method, it was possible to analyze the structure of the MTJ from a large number of human muscle fibers. The finding that the interface area between muscle and tendon is higher in type I compared with type II fibers suggests that type II fibers are less resistant to strain and therefore more susceptible to injury.

Natural, synthetic and commercially-available biopolymers used to regenerate tendons and ligaments

Tendon and ligament (TL) injuries affect millions of people annually. Biopolymers play a significant role in TL tissue repair, whether the treatment relies on tissue engineering strategies or using artificial tendon grafts. The biopolymer governs the mechanical properties, biocompatibility, degradation, and fabrication method of the TL scaffold. Many natural, synthetic and hybrid biopolymers have been studied in TL regeneration, often combined with therapeutic agents and minerals to engineer novel scaffold systems. However, most of the advanced biopolymers have not advanced to clinical use yet. Here, we aim to review recent biopolymers and discuss their features for TL tissue engineering. After introducing the properties of the native tissue, we discuss different types of natural, synthetic and hybrid biopolymers used in TL tissue engineering. Then, we review biopolymers used in commercial absorbable and non-absorbable TL grafts. Finally, we explain the challenges and future directions for the development of novel biopolymers in TL regenerative treatment.

The internal structure of the infraspinatus muscle: a magnetic resonance study

Purpose

This study aimed to describe the internal structure of the infraspinatus muscle. A secondary aim was to explore differences in internal structure between genders, sides, and correlations to demographic data.

Methods

In total, 106 shoulder MRI examinations of patients between 18 and 30 years of age seeking care in 2012–2020 at The Sahlgrenska University Hospital in Gothenburg, Sweden were re-reviewed.

Results

The number of intramuscular tendons centrally in the infraspinatus muscle varied between 3 and 8 (median = 5). Laterally, the number of intramuscular tendons varied between 1 and 5 (median = 2). There was no difference in the median between the genders or sides. No correlations between the number of intramuscular tendons and demographic data were found. The muscle volume varied between 63 and 249 ml with a median of 188 ml for males and 122 ml for females. There was no significant difference in volume between the sides. The muscle volume correlated with body weight (Pearson’s correlation coefficient, r = 0.72, p < 0.001) and height (r = 0.61, p < 0.001).

Conclusion

The anatomical variations of the infraspinatus muscle are widespread. In the medial part of the muscle belly, the number of intramuscular tendons varied between 3 and 8, while the number of intramuscular tendons laterally varied between 1 and 5. Results of our study may help to understand the internal structure of the infraspinatus muscle and its function in shoulder stabilization.

Three-dimensional mechanical characterization of murine skeletal muscle using quantitative micro-elastography

Skeletal muscle function is governed by both the mechanical and structural properties of its constituent tissues, which are both modified by disease. Characterizing the mechanical properties of skeletal muscle tissue at an intermediate scale, i.e., between that of cells and organs, can provide insight into diseases such as muscular dystrophies. In this study, we use quantitative micro-elastography (QME) to characterize the micro-scale elasticity of ex vivo murine skeletal muscle in three-dimensions in whole muscles. To address the challenge of achieving high QME image quality with samples featuring uneven surfaces and geometry, we encapsulate the muscles in transparent hydrogels with flat surfaces. Using this method, we study aging and disease in quadriceps tissue by comparing normal wild-type (C57BL/6J) mice with dysferlin-deficient BLAJ mice, a model for the muscular dystrophy dysferlinopathy, at 3, 10, and 24 months of age (sample size of three per group). We observe a 77% decrease in elasticity at 24 months in dysferlin-deficient quadriceps compared to wild-type quadriceps.

Manual and semi-automatic determination of elbow angle-independent parameters for a model of the biceps brachii distal tendon based on ultrasonic imaging

Tendons consist of passive soft tissue with non linear material properties. They play a key role in force transmission from muscle to skeletal structure. The properties of tendons have been extensively examined in vitro. In this work, a non linear model of the distal biceps brachii tendon was parameterized based on measurements of myotendinous junction displacements in vivo at different load forces and elbow angles. The myotendinous junction displacement was extracted from ultrasound B-mode images within an experimental setup which also allowed for the retrieval of the exerted load forces as well as the elbow joint angles. To quantify the myotendinous junction movement based on visual features from ultrasound images, a manual and an automatic method were developed. The performance of both methods was compared. By means of exemplary data from three subjects, reliable fits of the tendon model were achieved. Further, different aspects of the non linear tendon model generated in this way could be reconciled with individual experiments from literature.

The proteomic profile of the human myotendinous junction

Proteomics analysis of skeletal muscle has recently progressed from whole muscle tissue to single myofibers. Here, we further focus on a specific myofiber domain crucial for force transmission from muscle to tendon, the myotendinous junction (MTJ). To overcome the anatomical constraints preventing the isolation of pure MTJs, we performed in-depth analysis of the MTJ by progressive removal of the muscle component in semitendinosus muscle-tendon samples. Using detergents with increasing stringency, we quantified >3000 proteins across all samples, and identified 112 significantly enriched MTJ proteins, including 24 known MTJ-enriched proteins. Of the 88 novel MTJ markers, immunofluorescence analysis confirmed the presence of tetraspanin-24 (CD151), kindlin-2 (FERMT2), cartilage intermediate layer protein 1 (CILP), and integrin-alpha10 (ITGA10), at the human MTJ. Together, these human data constitute the first detailed MTJ proteomics resource that will contribute to advance understanding of the biology of the MTJ and its failure in pathological conditions.

Human Organ-on-a-Chip Microphysiological Systems to Model Musculoskeletal Pathologies and Accelerate Therapeutic Discovery

Human Microphysiological Systems (hMPS), otherwise known as organ- and tissue-on-a-chip models, are an emerging technology with the potential to replace in vivo animal studies with in vitro models that emulate human physiology at basic levels. hMPS platforms are designed to overcome limitations of two-dimensional (2D) cell culture systems by mimicking 3D tissue organization and microenvironmental cues that are physiologically and clinically relevant. Unlike animal studies, hMPS models can be configured for high content or high throughput screening in preclinical drug development. Applications in modeling acute and chronic injuries in the musculoskeletal system are slowly developing. However, the complexity and load bearing nature of musculoskeletal tissues and joints present unique challenges related to our limited understanding of disease mechanisms and the lack of consensus biomarkers to guide biological therapy development. With emphasis on examples of modeling musculoskeletal tissues, joints on chips, and organoids, this review highlights current trends of microphysiological systems technology. The review surveys state-of-the-art design and fabrication considerations inspired by lessons from bioreactors and biological variables emphasizing the role of induced pluripotent stem cells and genetic engineering in creating isogenic, patient-specific multicellular hMPS. The major challenges in modeling musculoskeletal tissues using hMPS chips are identified, including incorporating biological barriers, simulating joint compartments and heterogenous tissue interfaces, simulating immune interactions and inflammatory factors, simulating effects of in vivo loading, recording nociceptors responses as surrogates for pain outcomes, modeling the dynamic injury and healing responses by monitoring secreted proteins in real time, and creating arrayed formats for robotic high throughput screens. Overcoming these barriers will revolutionize musculoskeletal research by enabling physiologically relevant, predictive models of human tissues and joint diseases to accelerate and de-risk therapeutic discovery and translation to the clinic.

Morphological Changes in the Myotendinous Junction of mdx Mice

The myotendinous junction (MTJ) is the interface between muscle and tendon, and it is the main area of force transmission of the locomotor apparatus. Dystrophic processes promote pathological injury which affects the skeletal muscle and can influence the morphology of the MTJ. This study aimed to investigate the adaptations in MTJ morphology of mdx mice in the tibialis anterior muscle. Male mice (n = 24) were divided into Control—C57bl/10 and mdx—C57bl/10mdx (Duchenne muscular dystrophy experimental model). In the mdx group, centralized nuclei with a large area and greater deposition of type III collagen (fibrosis) were observed. Also, shorter sarcomeres and sarcoplasmatic projections of MTJ were observed. We concluded that the adaptations in mdx mice demonstrated extensive impairment in the MTJ region with reduced ultrastructures.

The Myotendinous Junction-A Vulnerable Companion in Sports. A Narrative Review

The incidence of strain injuries continues to be high in many popular sports, especially hamstring strain injuries in football, despite a documented important effect of eccentric exercise to prevent strains. Studies investigating the anatomical properties of these injuries in humans are sparse. The majority of strains are seen at the interface between muscle fibers and tendon: the myotendinous junction (MTJ). It has a unique morphology with a highly folded muscle membrane filled with invaginations of collagen fibrils from the tendon, establishing an increased area of force transmission between muscle and tendon. There is a very high rate of remodeling of the muscle cells approaching the MTJ, but little is known about how the tissue adapts to exercise and which structural changes heavy eccentric exercise may introduce. This review summarizes the current knowledge about the anatomy, composition and adaptability of the MTJ, and discusses reasons why strain injuries can be prevented by eccentric exercise.

Remnant Muscle Preservation on Hamstring Tendon Autograft During ACL Reconstruction Promotes Volumetric Increase With Biological and Regenerative Potential

Background

The removal of all adherent muscle tissue from the hamstring graft during anterior cruciate ligament reconstruction (ACLR) is common practice. However, there is a paucity of research to justify this removal or evaluate its biological implications.

Purpose/Hypothesis

The purpose of this study was to (1) evaluate the histological characteristics of the myotendinous muscle tissue harvested from hamstring tendons, (2) compare the final diameter of the prepared graft before and after the removal of the remnant musculature, and (3) evaluate patients who were treated with and without preservation of the graft-adhered muscle. The hypothesis was that the adherent musculature of the graft would have cells that could contribute to graft incorporation and revascularization, assist in the proprioceptive capacity of the neoligament, and increase the graft's diameter.

Study Design

Cohort study; Level of evidence, 3.

Methods

We divided 84 patients into 2 groups: group 1 underwent ACLR using hamstring tendon autograft with adherent musculature, and group 2 underwent ACLR using hamstring tendon autograft stripped of its remnant muscle. All patients had minimum 2-year follow-up. The muscle harvested from the graft in group 2 was submitted for histological examination, and the graft diameter before and after muscle removal was compared. The Tegner activity scale and Lysholm scores were determined preoperatively and at 12 and 24 months postoperatively.

Results

There was a significant difference in graft diameter between groups. The evaluation of the graft diameter in group 2 showed a decrease of 11.52% after removal of muscle tissue from the tendon graft. Patients from group 1 had better Tegner and Lysholm scores (mean ± SD) after 12 months (Tegner, 8.03 vs 7 [P = .004]; Lysholm, 95.48 ± 1.2 vs 87.54 ± 3.21 [P = .002]) and better Lysholm scores after 24 months (95.76 ± 2.1 vs 89.32 ± 2.47; P = .002). The muscle tissue of the analyzed fragments presented a pattern with fibrous tissue beams, invaginating regularly and sequentially from the myotendinous junction into the muscles.

Conclusion

Preserving the muscle tissue on tendon grafts promoted a volumetric increase in the final autograft diameter and demonstrated biological and regenerative potential. Patients who underwent ACLR using the tendon with the muscle attached had better functional scores at 2-year follow-up as compared with patients treated using the tendon with the muscle removed.

Bringing tendon biology to heel: Leveraging mechanisms of tendon development, healing, and regeneration to advance therapeutic strategies

Tendons are specialized matrix-rich connective tissues that transmit forces from muscle to bone and are essential for movement. As tissues that frequently transfer large mechanical loads, tendons are commonly injured in patients of all ages. Following injury, mammalian tendons heal poorly through a slow process that forms disorganized fibrotic scar tissue with inferior biomechanical function. Current treatments are limited and patients can be left with a weaker tendon that is likely to rerupture and an increased chance of developing degenerative conditions. More effective, alternative treatments are needed. However, our current understanding of tendon biology remains limited. Here, we emphasize why expanding our knowledge of tendon development, healing, and regeneration is imperative for advancing tendon regenerative medicine. We provide a comprehensive review of the current mechanisms governing tendon development and healing and further highlight recent work in regenerative tendon models including the neonatal mouse and zebrafish. Importantly, we discuss how present and future discoveries can be applied to both augment current treatments and design novel strategies to treat tendon injuries.

In the human, true myocutaneous junctions of skeletal muscle fibers are limited to the face

Within the panniculus carnosus‐associated skeletal muscles in the human, the palmaris brevis and the platysma showed myotendinous/myofascial junctions with clear distance to the corium and the specific connection collagen type XXII. The orbicularis oris muscle, in contrast, contained bundles of striated muscle fibers reaching the corium at two distinct levels: the predominant inner ending was connected to the elastic network of the inner corium and the outer ending was within the more superficial collagen network. At both locations, the striated muscle fibers showed brush‐like cytoplasmic protrusions connecting a network which was not oriented toward the muscle fibers. Collagen type XXII was not present.

Extracellular matrix at the muscle - tendon interface: functional roles, techniques to explore and implications for regenerative medicine

The muscle-tendon interface is an anatomically specialized region that is involved in the efficient transmission of force from muscle to tendon. Due to constant exposure to loading, the interface is susceptible to injury. Current treatment methods do not meet the socioeconomic demands of reduced recovery time without compromising the risk of reinjury, requiring the need for developing alternative strategies. The extracellular matrix (ECM) present in muscle, tendon, and at the interface of these tissues consists of unique molecules that play significant roles in homeostasis and repair. Better, understanding the function of the ECM during development, injury, and aging has the potential to unearth critical missing information that is essential for accelerating the repair at the muscle-tendon interface. Recently, advanced techniques have emerged to explore the ECM for identifying specific roles in musculoskeletal biology. Simultaneously, there is a tremendous increase in the scope for regenerative medicine strategies to address the current clinical deficiencies. Advancements in ECM research can be coupled with the latest regenerative medicine techniques to develop next generation therapies that harness ECM for treating defects at the muscle-tendon interface. The current work provides a comprehensive review on the role of muscle and tendon ECM to provide insights about the role of ECM in the muscle-tendon interface and discusses the latest research techniques to explore the ECM to gathered information for developing regenerative medicine strategies.

Return to Play and Recurrence After Calf Muscle Strain Injuries in Elite Australian Football Players

BACKGROUND

Calf muscle strain injuries (CMSI) are prevalent in sport, but information about factors associated with time to return to play (RTP) and recurrence is limited.

PURPOSE

To determine whether clinical and magnetic resonance imaging (MRI) data are associated with RTP and recurrence after CMSI.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data of 149 CMSI reported to the Soft Tissue injury Registry of the Australian Football League were explored to evaluate the impact of clinical data and index injury MRI findings on RTP and recurrence. Clinical data included age, previous injury history, ethnicity, and the mechanism of injury.

RESULTS

Irrespective of the anatomical location, players with CMSI with severe aponeurotic disruption (AD) took longer to RTP than players with CMSI with no AD: 31.3 ± 12.6 days vs 19.4 ± 10.8 days (mean ± SD; P = .003). A running-related mechanism of injury was associated with a longer RTP period for CMSI overall (adjusted hazard ratio [AHR], 0.59; P = .02). The presence of AD was associated with a longer RTP period for soleus injuries (AHR, 0.6; P = .025). Early recurrence (ie, ≤2 months of the index injury) was associated with older age (AHR, 1.3; P = .001) and a history of ankle injury (AHR, 3.9; P = .032). Older age (AHR, 1.1; P = .013) and a history of CMSI (AHR, 6.7; P = .002) increased the risk of recurrence within 2 seasons. The index injury MRI findings were not associated with risk of recurrence.

CONCLUSION

A running-related mechanism of injury and the presence of AD on MRI were associated with a longer RTP period. Clinical rather than MRI data best indicate the risk of recurrent CMSI.

Skeletal Muscle Extracellular Matrix - What Do We Know About Its Composition, Regulation, and Physiological Roles? A Narrative Review

Skeletal muscle represents the largest body-composition component in humans. In addition to its primary function in the maintenance of upright posture and the production of movement, it also plays important roles in many other physiological processes, including thermogenesis, metabolism and the secretion of peptides for communication with other tissues. Research attempting to unveil these processes has traditionally focused on muscle fibers, i.e., the contractile muscle cells. However, it is a frequently overlooked fact that muscle fibers reside in a three-dimensional scaffolding that consists of various collagens, glycoproteins, proteoglycans, and elastin, and is commonly referred to as extracellular matrix (ECM). While initially believed to be relatively inert, current research reveals the involvement of ECM cells in numerous important physiological processes. In interaction with other cells, such as fibroblasts or cells of the immune system, the ECM regulates muscle development, growth and repair and is essential for effective muscle contraction and force transmission. Since muscle ECM is highly malleable, its texture and, consequently, physiological roles may be affected by physical training and disuse, aging or various diseases, such as diabetes. With the aim to stimulate increased efforts to study this still poorly understood tissue, this narrative review summarizes the current body of knowledge on (i) the composition and structure of the ECM, (ii) molecular pathways involved in ECM remodeling, (iii) the physiological roles of muscle ECM, (iv) dysregulations of ECM with aging and disease as well as (v) the adaptations of muscle ECM to training and disuse.

Posture-related stiffness mapping of paraspinal muscles

The paraspinal compartment acts as a bone-muscle composite beam of the spine. The elastic properties of the paraspinal muscles play a critical role in spine stabilization. These properties depend on the subjects' posture, and they may be drastically altered by low back pain. Supersonic shear wave elastography can be used to provide quantitative stiffness maps (elastograms), which characterize the elastic properties of the probed tissue. The aim of this study was to challenge shear wave elastography sensitivity to postural stiffness changes in healthy paraspinal muscles. The stiffness of the main paraspinal muscles (longissimus, iliocostalis, multifidus) was measured by shear wave elastography at the lumbosacral level (L3 and S1) for six static postures performed by volunteers. Passive postures (rest, passive flexion, passive extension) were performed in a first shear wave elastography session, and active postures (upright, bending forward, bending backward) with rest posture for reference were performed in a second session. Measurements were repeated three times for each posture. Sixteen healthy young adults were enrolled in the study. Non-parametric paired tests, multiple analyses of covariance, and intra-class correlations were implemented for analysis. Shear wave elastography showed good to excellent reliability, except in the multifidus at S1, during bending forward, and in the multifidus at L3, during bending backward. Yet, during bending forward, only poor quality was recorded for nine volunteers in the longissimus. Significant intra- and inter-muscular changes were observed with posture. Stiffness significantly increased for the upright position and bending forward with respect to the reference values recorded in passive postures. In conclusion, shear wave elastography allows reliable assessment of the stiffness of the paraspinal muscles except in the multifidus at S1 and longissimus, during bending forward, and in the multifidus at L3, during bending backward. It reveals a different biomechanical behaviour for the multifidus, the longissimus, and the iliocostalis.

Mechanical force regulates tendon extracellular matrix organization and tenocyte morphogenesis through TGFbeta signaling

Mechanical forces between cells and extracellular matrix (ECM) influence cell shape and function. Tendons are ECM-rich tissues connecting muscles with bones that bear extreme tensional force. Analysis of transgenic zebrafish expressing mCherry driven by the tendon determinant scleraxis reveals that tendon fibroblasts (tenocytes) extend arrays of microtubule-rich projections at the onset of muscle contraction. In the trunk, these form a dense curtain along the myotendinous junctions at somite boundaries, perpendicular to myofibers, suggesting a role as force sensors to control ECM production and tendon strength. Paralysis or destabilization of microtubules reduces projection length and surrounding ECM, both of which are rescued by muscle stimulation. Paralysis also reduces SMAD3 phosphorylation in tenocytes and chemical inhibition of TGFβ signaling shortens tenocyte projections. These results suggest that TGFβ, released in response to force, acts on tenocytes to alter their morphology and ECM production, revealing a feedback mechanism by which tendons adapt to tension.

Organization of the fascia and aponeurosis in the lumbar paraspinal compartment

PURPOSE

The thoracolumbar fascia (TLF) and the erector spinae aponeurosis (ESA) play significant roles in the biomechanics of the spine and could be a source of low back pain. Attachment, collagen fiber direction, size and biomechanical properties of the TLF have been well documented. However, questions remain about the attachment of the TLF and ESA in relation to adjoining tissues in the lumbosacral region. Moreover, quantitative data in relation to the ESA have rarely been examined. The aim of this study was to further investigate the anatomical features of the TLF and ESA and to determine the attachments and sliding areas of the paraspinal compartment through dissection.

MATERIALS AND METHODS

In 10 fresh cadavers (6 females, 4 males, mean age: 77 ± 10 years), we determined (1) the gross anatomy of the ESA and the TLF (attachments and sliding areas) and (2) the structure of the ESA and the TLF (thickness, width, orientation of collagen fibers). The pennation angle between the axis of the ES muscle fibers and the axis of the collagen fibers of the ESA were also measured.

RESULTS

The TLF is an irregular dense connective tissue with a mean thickness of 0.95 mm. The distance between the spinous processes line and the site where the neurovascular bundles pierced the TLF, depending on the vertebral level, ranged from 29 mm at L1 to 75 mm at L3. The ESA constituted a band of regular longitudinally oriented connective fibers (mean thickness: 1.85 mm). Muscles fibers of the ES were strongly diagonally attached to the ESA (mean pennation angle 8° for the iliocostalis and 14° for the longissimus). To a lesser extent, the superficial multifidi were attached to the ESA at the lumbar level close to the midline and at the sacral level.

CONCLUSION

The ESA, at twice the thickness of the pTLF, was the thickest dense connective tissue of the paraspinal compartment. The ESA and the TLF circumscribed subcompartments and sliding areas between the TFL and the lumbar paraspinal muscles, between the ES and the multifidus, and between the longissimus and the iliocostalis.

Remodeling of muscle fibers approaching the human myotendinous junction

The myotendinous junction (MTJ) is at high risk of strain injuries, due to high amounts of energy that is transferred through this structure. The risk of strain injury is significantly reduced by heavy resistance training (HRT), indicating a remodeling capacity of MTJ. We investigated the degree of remodeling of muscle fibers near the human MTJ. In 8 individuals, samples were taken from the semitendinosus and gracilis MTJ and they were stained immunohistochemically for myonuclei (DAPI), fibroblasts (TCF7L2), and satellite cells (CD56). A high portion of the muscle fibers adjacent to the MTJ contained a centrally located myonucleus (47 ± 8%, mean ± SD) and half of the muscle fibers were CD56 positive. The number of satellite cells and fibroblasts were not higher than what has previously been reported from muscle bellies. The immunohistochemical findings suggest that the rate of remodeling of muscle fibers near the MTJ is very high. The finding that there was no increased number of satellite cells and fibroblasts could be explained as a dynamic phenomenon. The effect of HRT should be evaluated in a randomized setting.

MR Imaging of Muscle Trauma: Anatomy, Biomechanics, Pathophysiology, and Imaging Appearance

Muscle is an important component of the muscle-tendon-bone unit, driving skeletal motion through contractions that alter the length of the muscle. The muscle and myotendinous junction (MTJ) are most commonly injured in the young adult, as a result of indirect mechanisms such as overuse or stretching, direct impact (penetrating or nonpenetrating), or dysfunction of the supporting connective tissues. Magnetic resonance (MR) imaging is widely used for assessment of muscle injuries. This review illustrates the MR imaging appearance of a broad spectrum of acute, subacute, and chronic traumatic lesions of muscle, highlighting the pathophysiology, biomechanics, and anatomic considerations underlying these lesions. Concentric (shortening) contractions are more powerful, but it is eccentric (lengthening) contractions that produce the greatest muscle tension, leading to indirect injuries such as delayed-onset muscle soreness (DOMS) and muscle strain. Strain is the most commonly encountered muscle injury and is characteristically located at the MTJ, where maximal stress accumulates during eccentric exercise. The risk of strain varies among muscles based on their fiber composition, size, length, and architecture, with pennate muscles being at highest risk. Direct impact to muscle results in laceration or contusion, often accompanied by intramuscular interstitial hemorrhage and hematoma. Disorders related to the muscle's collagen framework include compartment syndrome, which is related to acute or episodic increases in pressure, and muscle herniation through anatomic defects in the overlying fascia. The healing response after muscle trauma can result in regeneration, degeneration with fibrosis and fatty replacement, or disordered tissue proliferation as seen in myositis ossificans. In athletes, accurate grading of the severity and precise location of injury is necessary to guide rehabilitation planning to prevent reinjury and ensure adequate healing. In elite athletes, MR imaging grading of muscle trauma plays an increasingly important role in recently developed comprehensive grading systems that are replacing the imprecise three-grade injury classification system currently used. ^©RSNA, 2017.

Composition and adaptation of human myotendinous junction and neighboring muscle fibers to heavy resistance training

The myotendinous junction (MTJ) is a common site of strain injury and yet understanding of its composition and ability to adapt to loading is poor. The main aims of this study were to determine the profile of selected collagens and macrophage density in human MTJ and adjoining muscle fibers, and to investigate whether heavy exercise loading would alter this profile. Fifteen individuals scheduled for anterior cruciate ligament repair surgery were randomized into three groups: control, acute or 4 weeks heavy resistance training. MTJ samples were collected from the semitendinosus and gracilis muscles and were sectioned and stained immunohistochemically for collagen types I, III, VI, XII, XIV, XXII, Tenascin-C and CD68. Macrophage density and distribution was evaluated and the amount of each collagen type in muscle and MTJ was graded. Collagen XXII was observed solely at the MTJ, while all other collagens were abundant at the MTJ and in muscle perimysium or endomysium. The endomysial content of collagen XIV, macrophages and Tenascin-C increased following 4 weeks of training. These findings illustrate the heterogeneity of collagen type composition of human MTJ. The increase in collagen XIV following 4 weeks of training may reflect a training-induced protection against strain injuries in this region.

Effect of Different Exercise Intensities on the Myotendinous Junction Plasticity

Myotendinous junctions (MTJs) are anatomical regions specialized in transmission of contractile strength from muscle to tendon and, for this reason, a common site where acute injuries occur during sport activities. In this work we investigated the influence of exercise intensity on MTJ plasticity, as well as on the expression of insulin-like growth factor 1 (IGF-1) and transforming growth factor beta (TGF-β) and their receptors in muscle and tendon. Three groups of rats were analyzed: control (CTRL), slow-runner (RUN-S) and fast-runner (RUN-F) trained using a treadmill. Ultrastructural and morphometric analyses of distal MTJs from extensor digitorum longus muscles have been performed. Contractile strength and hypertrophy were investigated by using in vivo tension recordings and muscle cross-sectional area (CSA) analysis, respectively. mRNA levels of PGC-1α, vinculin, IGF-1Ea and TGF-β have been quantified in muscle belly, while IGF-1Ea, TGF-β and their receptors in tendon. Morphometry revealed an increased MTJ complexity and interaction surface between tissues in trained rats according to training intensity. CSA analysis excluded hypertrophy among groups, while muscle strength was found significantly enhanced in exercised rats in comparison to controls. In muscle tissue, we highlighted an increased mRNA expression of PGC-1α and vinculin in both trained conditions and of TGF-β in RUN-F. In tendon, we mainly noted an enhancement of TGF-β mRNA expression only in RUN-F group and a raise of Betaglycan tendon receptor mRNA levels proportional to exercise intensity. In conclusion, MTJ plasticity appears to be related to exercise intensity and molecular analysis suggests a major role played by TGF-β.

Tendon Structure and Composition

Tendons are soft, fibrous tissues that connect muscle to bone. Their main function is to transfer muscle generated force to the bony skeleton, facilitating movement around a joint, and as such they are relatively passive, inelastic structures, able to resist high forces. Tendons are predominantly composed of collagen, which is arranged in a hierarchical manner parallel to the long axis of the tendon, resulting in high tensile strength. Tendon also contains a range of non-collagenous proteins, present in low amounts, which nevertheless have important functional roles. In this chapter, we describe general tendon composition and structure, and discuss how variations in composition and structure at different levels of the tendon hierarchy confer specific mechanical properties, which are related to tendon function.