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3. Biomechanics
a. Tendons have high tensile properties and buckle under compression (ie, they behave like ropes).
A typical load-elongation curve for tendon includes a toe region, a linear region, and a failure
region (
Figure 2).
b. Tendon biomechanics can be characterized by either structural properties (load-elongation
behavior) or material properties (stress-strain behavior, where stress is calculated by dividing
[Figure 1. Tendon tissue has a highly ordered hierarchical structure.]
[Figure 2. The tensile behavior of tendon and ligament tissue includes a nonlinear toe region at
low loads, a linear region at intermediate loads, and a failure region at high loads.]
load by cross-sectional area and strain is calculated by dividing change in elongation by initial
length).
i. Structural properties describe the overall load-bearing capacity of the tissue and include the
contribution of the muscle and bone attachments as well as the geometry of the tissue (crosssectional area and length). Structural properties include stiffness (the slope of the linear portion
of the curve in Figure 2) and failure load.
ii. Material properties (also referred to as mechanical properties) describe the quality of the tissue
by normalizing for tissue geometry. Material properties include the modulus of elasticity (the
slope of the linear portion of the stress-strain curve) and failure stress.
c. Tendons exhibit viscoelastic behavior; the mechanical properties of the tissue are dependent on
loading history and time. Time dependence is best illustrated by the phenomena of creep and
stress relaxation.
i. Stress relaxationThe decrease in load/stress for a constant elongation/strain.
ii. CreepThe increase in elongation/strain for a constant applied load/stress.
d. Several factors influence the biomechanical properties of tendons.
i. Anatomic locationTendons from different locations have different structural properties; eg,
digital flexor tendons have twice the ultimate strength of digital extensor tendons.
ii. Exercise and immobilizationExercise has a positive effect and immobilization has a
detrimental effect on the biomechanical properties of tendons (
Figure 3).
[Figure 3. Immobilization leads to a dramatic drop in mechanical properties, and exercise has a
positive effect on mechanical properties.]
iii. AgeMaterial and structural properties of tendons increase from birth through maturity. The
properties then decrease from maturity through old age.
iv. Laser/heat treatment causes tendons to shrink. Long-term effects are unclear, but early evidence
suggests that laser/heat treatment has a detrimental effect on the biomechanical properties of the
tissue.
e. Factors to consider when mechanically testing tendons:
i. The mechanical properties of tendons vary with hydration, temperature, and pH, so tendons
should be tested under physiologically relevant hydration, temperature, and pH conditions.
ii. The high strength of tendons leads to difficulty in gripping the tissue during mechanical testing.
Specialized grips (eg, freeze clamps) are often necessary to prevent the tendon from slipping out
of the grip.
iii. Knowledge of tissue cross-sectional area is necessary for the calculation of stress (recall that
stress = load/cross-sectional area). Care must be taken when measuring the cross-sectional area
of tendon because the tissue will deform if contact methods are used (eg, calipers).
iv. Because tendons are viscoelastic (their properties are time dependent), the rate at which the
tendon is pulled can influence the mechanical properties. Higher strain rates result in a higher
elastic modulus.
v. Specimens should be stored frozen and properly hydrated. Improper storage may affect tendon
mechanical properties.
vi. The orientation of a tendon during testing will influence the mechanical properties measured;
eg, the structural properties of the supraspinatus tendon depends on the angle of the humeral
head relative to the glenoid.
B. Injury, repair, and healing
1. Tendon injury occurs because of direct trauma (eg, laceration of a flexor tendon) or indirect
tensile overload (eg, Achilles tendon rupture).
2. Three phases of healing:
a. Hemostasis/inflammationAfter injury, the wound site is infiltrated by inflammatory cells.
Platelets aggregate at the wound and create a fibrin clot to stabilize the torn tendon edges. The
length of this phase is on the order of days.
b. Matrix and cell proliferationFibroblasts infiltrate the wound site and proliferate. They produce
extracellular matrix, including large amounts of type III collagen. The injury response in adult
tendon is scar mediated (ie, large amounts of disorganized collagen are deposited at the repair
site). The length of this phase is on the order of weeks.
Figure 5).
i. Ligaments are shorter and wider.
ii. Ligaments have a lower percentage of collagen and a higher percentage of proteoglycans and
water.
[Figure 5. The biochemical composition of a typical ligament.]
iii. Collagen fibers are less organized in ligaments.
c. Ligaments have a highly ordered hierarchical structure, similar to tendons.
d. Type I collagen makes up 70% of the dry weight of ligaments.
e. Like tendons, the main cell type in ligaments is the fibroblast, but ligament fibroblasts appear
rounder than tendon fibroblasts.
f. Ligaments have relatively low vascularity and cellularity.
3. Biomechanics
a. The biomechanical properties of ligaments are expressed as either the structural properties of the
bone-ligament-bone complex or the material properties of the ligament midsubstance itself.
b. Ligaments exhibit viscoelastic behavior similar to that of tendons.
c. Several factors that influence the mechanical properties of ligaments are the same as those
described earlier for tendon (I.A.3.d).
d. Factors that must be considered when mechanically testing ligaments are the same as those listed
earlier for tendon (I.A.3.e).
B. Injury, repair, and healing
1. Ligament injuries are generally classified into three grades (I, II, and III). Grade I corresponds to
a mild sprain, grade II corresponds to a moderate sprain/partial tear, and grade III corresponds to
a complete ligament tear. An additional type of injury is avulsion of the ligament from its bony
insertion.
2. Ligament healing occurs through the same phases as tendon healing (hemostasis/inflammation,
matrix and cell proliferation, remodeling/maturation).
3. Extra-articular ligaments (eg, the medial collateral ligament (MCL) of the knee) have a greater
capacity to heal than do intra-articular ligaments (eg, ACL of the knee).
a. MCL of the knee
iii. Third zone: mineralized fibrocartilage, indicating a marked transition toward bony tissue.
Predominant collagen is type II, with significant amounts of type X collagen and aggrecan.
iv. Zone four: bone, which is made up predominantly of type I collagen with a high mineral
content.
c. Although the insertion site is typically categorized into four zones, changes in the tissue are
gradual and continuous. This continuous change in tissue composition is presumed to aid in the
efficient transfer of load between two very different materials.
3. Biomechanics
a. A fibrocartilaginous transition is necessary to reduce stress concentrations that would otherwise
arise at the interface of two very different materials (tendon/ligament and bone).
b. The enthesis typically has lower mechanical properties in tension than does the tendon or
ligament midsubstance.
B. Injury, repair, and healing
1. Tendon-to-bone and ligament-to-bone healing is necessary in several scenarios.
a. Rotator cuff injuries, which represent most soft-tissue injuries to the upper extremities,
commonly require surgical repair to the humeral head.
b. Typical ACL reconstruction techniques use tendon grafts that must heal in tibial and femoral
bone tunnels.
c. Avulsion injuries to the flexor tendons of the hand require tendon-to-bone repair.
2. In most cases of tendon-to-bone healing, clinical outcomes have been disappointing. The most
dramatic feature of the failed healing response is the lack of a transition zone between the
healing tendon and bone. Regeneration of the natural transitional tissue between tendon and bone
is critical for the restoration of joint function and for the prevention of reinjury.
IV. Tissue Engineering
A. General
1. DefinitionTissue engineering is the regeneration of injured tissue through the merging of three
areas: scaffold microenvironment, responding cells, and signaling biofactors.
2. Tissue engineering holds great promise for improving tendon and ligament repair.
B. Scaffold
1. Can serve as a delivery system for biofactors, an environment to attract or immobilize cells,
and/or a mechanical stabilizer.
2. Scaffold matrices commonly are made of collagen, fibrin, polymer, or silk.
C. Responding cells
1. Tendon/ligament fibroblasts, mesenchymal stem cells
2. May either be seeded onto the scaffold before implantation or may infiltrate the acellular scaffold
after it is implanted.
D. Signaling biofactors
1. Growth factors
a. Platelet-derived growth factor-BB (PDGF-BB) promotes cell proliferation and matrix synthesis.
b. Transforming growth factor-beta (TGF-) promotes matrix synthesis.
c. Basic fibroblast growth factor (bFGF) promotes cell proliferation and matrix synthesis.
2. Mechanical signals
a. Cyclic tensile loads promote matrix synthesis.
b. Compressive loads promote proteoglycan production.
Top Testing Facts
1. Tendons and ligaments are materials with highly ordered hierarchical structure.
2. The composition of tendons and ligaments is primarily type I collagen, aligned in the direction of
loading (anisotropic).
3. Structural properties describe the capacity of the tissue to bear load; material properties describe
the quality of the tissue.
4. Tendons and ligaments are viscoelastic (their properties are time dependent).
5. Several biologic (eg, age) and environmental (eg, temperature) factors influence the mechanical
properties of tendons and ligaments.
6. Tendon/ligament healing progresses through clearly defined phases: hemostasis/inflammation,
matrix and cell proliferation, and remodeling/maturation.
7. Nonsheathed tendons and extra-articular ligaments have a greater capacity to heal than do
sheathed tendons and intra-articular ligaments.
8. For tendon and ligament healing, increased loading can be either beneficial or detrimental,
depending on the anatomic location and type of injury.
9. The physical environment influences tissue maintenance: immobilization is detrimental and
exercise is beneficial to the biomechanical properties of these tissues (tendon and ligament).
10. The tendon/ligament enthesis is a specialized tissue that is necessary to minimize stress
concentrations at the interface between two very different materials (tendon/ligament and bone).