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Muscle Injury in the Athlete pp 53–72Cite as

Healing Processes in Tendon Tissue

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Abstract

To further our understanding of the biological principles at the basis of tendon tissue repair, this chapter offers a concise yet detailed overview of the various phases involved in the healing of tendon tissue subjected to injury or surgery. A complete understanding of these biological principles is required not only if we are to appreciate how tissue lesion may develop, and if we are to recognize the factors which will hinder a full structural and functional recovery, but also if we intend to efficiently channel the natural healing processes of the damaged tendon. As with all soft tissue, the healing processes of tendon tissue can be seen to follow three biological pathways: regeneration, repair, or a combination of both. During regeneration, the structural and fundamental characteristics of the original tissue are faithfully reproduced by the new tissue (Leadbetter 1995a; b). Therefore, in theory, tissue regeneration represents the ideal healing process for injured soft tissue as it does for striated skeletal muscle (Bisciotti 2010). However, as tendons heal, scar tissue, albeit connective tissue with structural and functional properties inferior to those of the original tendon tissue, appears to varying degrees just as it does when skeletal muscle heals (Józsa and Kannus 1997). Compared to striated muscle, tendon tissue presents a lesser ability to self-repair as it is less vascularized and therefore relatively less replenished with nutrients and oxygen. Nonetheless, several authors maintain that the self-healing ability of tendons is underestimated (Holch et al. 1994; Maagaard-Mortensen et al. 1994; Zwipp 1995).

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Notes

  1. 1.

    Tryptase is a proteolytic enzyme present in mast cell granules.

  2. 2.

    Myofibroblasts are connective tissue cells with a contractility similar to that of smooth muscle. These cells were first isolated in 1970 and have since been shown to play an important role in the process of wound healing, tissue fibrosis, and pathological fascicular contractures. Their natural cycle sees them evolving from normal fibroblasts to proto-myofibroblasts, subsequently fully differentiating into myofibroblasts, and finally succumbing to the process of apoptosis that is strongly influenced by mechanical tension, cytokines and specific proteins of the extracellular matrix.

  3. 3.

    NO synthase is an ubiquitous tissue enzyme present in the majority of living organisms that participates in NO production by converting arginine into citrulline (an intermediate metabolite of the urea cycle).

  4. 4.

    The protein scleraxis (Locus: Chr. 8 q24.3) is a member of the superfamily of transcription factors with a basic-helix-loop-helix (bHLH). It is expressed both in mature tendons and ligaments of the limbs and torso, but also in their progenitors. The Scx gene is expressed in all connective tissues that tie muscle to bone structures, as well as in their progenitors that are found in primitive mesenchymal tissue.

  5. 5.

    A dimer is a macromolecule formed by the union of two subunits called monomers. Homodimers arise from the association of identical monomers whereas heterodimers arise from the association of different monomers.

  6. 6.

    An E-box is a DNA hexanucleotide consensus sequence that is typically located upstream from a gene in a “promoter region.”

  7. 7.

    In molecular biology and bioinformatics, a “consensus sequence” refers to the most frequent amino acid or nucleotide in a particular position in multiple sequence alignments.

  8. 8.

    Somite: [from the Greek soma, body-ite]. In embryology, each of the segments in to which the dorsal mesoderm/epimer, left and right of the spinal column, is divided. The somites give rise to elements that will form the dermis of the trunk (dermatomes), the muscles (myotomes) and the axial skeleton (sclerotomi).

  9. 9.

    The myogenic regulatory factors are transcription factors characterized by the secondary structural motif “basic helix-loop-helix” (bHLH); a basic domain involved in binding DNA, and a HLH domain which forms quaternary structures, homo- or heterodimer complexes with other proteins also containing HLH domains. The bHLH motif is found in many transcription factors that are ubiquitously expressed in a tissue-specific manner.

  10. 10.

    The MyoD gene encodes a transcription factor involved in the differentiation of muscle and, in particular, induces fibroblasts to differentiate into myoblasts.

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Authors and Affiliations

  1. Head of Medical Department, F.C. Internazionale, Milano, Italy

    Piero Volpi

  2. Istituto Clinico Humanitas, Milano, Italy

    Piero Volpi

  3. FIFA Center of Excellence, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar

    Gian Nicola Bisciotti

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  1. Piero Volpi
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  2. Gian Nicola Bisciotti
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Volpi, P., Bisciotti, G.N. (2019). Healing Processes in Tendon Tissue. In: Muscle Injury in the Athlete. Springer, Cham. https://doi.org/10.1007/978-3-030-16158-3_3

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  • DOI: https://doi.org/10.1007/978-3-030-16158-3_3

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