Hechmi Toumi

Where tendons and ligaments meet bone: attachment sites (‘entheses’) in relation to exercise and/or mechanical load

Entheses (insertion sites, osteotendinous junctions, osteoligamentous junctions) are sites of stress concentration at the region where tendons and ligaments attach to bone. Consequently, they are commonly subject to overuse injuries (enthesopathies) that are well documented in a number of sports. In this review, we focus on the structure–function correlations of entheses on both the hard and the soft tissue sides of the junction. Particular attention is paid to mechanical factors that influence form and function and thus to exploring the relationship between entheses and exercise. The molecular parameters indicative of adaptation to mechanical stress are evaluated, and the basis on which entheses are classified is explained. The application of the ‘enthesis organ’ concept (a collection of tissues adjacent to the enthesis itself, which jointly serve the common function of stress dissipation) to understanding enthesopathies is considered and novel roles of adipose tissue at entheses are reviewed. A distinction is made between different locations of fat at entheses, and possible functions include space‐filling and proprioception. The basic anchorage role of entheses is considered in detail and comparisons are explored between entheses and other biological ‘anchorage’ sites. The ability of entheses for self‐repair is emphasized and a range of enthesopathies common in sport are reviewed (e.g. tennis elbow, golfers elbow, jumpers knee, plantar fasciitis and Achilles insertional tendinopathies). Attention is drawn to the degenerative, rather than inflammatory, nature of most enthesopathies in sport. The biomechanical factors contributing to the development of enthesopathies are reviewed and the importance of considering the muscle–tendon–bone unit as a whole is recognized. Bony spur formation is assessed in relation to other changes at entheses which parallel those in osteoarthritic synovial joints.

The inflammatory response: friend or enemy for muscle injury?

Limiting certain aspects of inflammation may be a useful new treatment for sport related muscle injury.

The role of neutrophils in injury and repair following muscle stretch

Stretch injury to the myotendinous junction is a common problem in competitive athletes and those involved in regular physical activity. The major risk factor for recurrent injury appears to be the primary injury itself. Physicians, physical therapists, athletic trainers and athletes alike continue to search for optimal treatment and prevention strategies. Acute inflammation is regarded as the bodys generalized protective response to tissue injury. An especially important and unexplored aspect of inflammation following injury is the role of inflammatory cells in extending injury and possibly directing muscle repair. It has been suggested that the inflammatory reaction, although it typically represents a reaction to damage and necrosis, may even bring about some local damage of its own and therefore increase the possibility for scarring and fibrosis. Limiting certain aspects of inflammation may theoretically reduce muscle damage as well as signals for muscle scarring. Here we focus on the role of neutrophils in injury and repair of stretch‐injured skeletal muscle. A minimally invasive model that generates a reproducible injury to rabbit skeletal muscle is presented. We present a plausible theory that neutrophil‐derived oxidants resulting from the initial stretch injury are responsible for extending the damage. An anti‐CD11b antibody that blocks the neutrophils respiratory burst is employed to reduce myofibre damage. An intriguing area that is currently being explored in our laboratory and others is the potential role for neutrophils to contribute to muscle growth and repair. It may be possible that neutrophils facilitate muscle repair through removal of tissue debris as well as by activation of satellite cells. Recent and ongoing investigations point to interleukin‐6 as a possible key cytokine in muscle inflammation and repair. Studies to elucidate a clearer understanding of this possibility will be reviewed.

The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome

Iliotibial band (ITB) syndrome is a common overuse injury in runners and cyclists. It is regarded as a friction syndrome where the ITB rubs against (and ‘rolls over’) the lateral femoral epicondyle. Here, we re‐evaluate the clinical anatomy of the region to challenge the view that the ITB moves antero‐posteriorly over the epicondyle. Gross anatomical and microscopical studies were conducted on the distal portion of the ITB in 15 cadavers. This was complemented by magnetic resonance (MR) imaging of six asymptomatic volunteers and studies of two athletes with acute ITB syndrome. In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30° of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.

Distinct topography of erosion and new bone formation in achilles tendon enthesitis: Implications for understanding the link between inflammation and bone formation in spondylarthritis

OBJECTIVE This study combined ultrasonography of the Achilles tendon enthesis at different stages of spondylarthritis (SpA) with microanatomic studies of normal cadaveric entheses, with the aim of exploring the relationship between bone erosion and new bone formation in enthesitis. METHODS Thirty-seven patients with SpA and Achilles tendon enthesitis (20 with early SpA and 17 with chronic SpA) and 10 normal control subjects underwent ultrasound scanning. The presence of bone erosion and spur formation was recorded at 3 sites: the proximal and distal halves of the enthesis and the adjacent calcaneal superior tuberosity. Parallel histologic analysis was performed on cadaveric Achilles tendon entheses to determine whether regional variations in bone density and trabecular architecture in relation to fibrocartilage distribution are related to disease patterns. RESULTS Bone erosion in patients with early SpA occurred at either the proximal insertion or the superior tuberosity (11 of 20 patients; P < 0.001 versus distal enthesis). Very small spurs, which were present almost exclusively at the distal enthesis, were evident in patients with early SpA and in normal control subjects. However, large spurs were evident distally only in patients with chronic SpA (9 of 17 patients, compared with none of 20 patients with early SpA; P < 0.0001). Histologic studies showed that aged normal individuals had small spurs at the corresponding location. The bone-to-marrow ratio was also significantly lower in the regions prone to erosions (P < 0.05). CONCLUSION Bone erosion in association with Achilles tendon enthesitis in SpA is anatomically uncoupled from bone formation-the 2 processes are topographically and temporally distinct. We thus conclude that disease patterns in SpA are related to normal enthesis structure and biomechanics.

Combined high-resolution magnetic resonance imaging and histological examination to explore the role of ligaments and tendons in the phenotypic expression of early hand osteoarthritis.

Background: The pathogenesis of the early stages of hand osteoarthritis is poorly understood, but recent high-resolution magnetic resonance imaging (hrMRI) studies suggest that the joint ligaments have a major role in the phenotypic expression of the disease. Objective: To combine hrMRI and cadaveric histological studies to better understand the mechanisms of damage, and especially the role of joint ligaments and tendons in disease expression. Methods: hrMRI was carried out in the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints in 20 patients with osteoarthritis,with a disease duration ⩽12 months. Histological sections of the DIP and PIP joints were obtained from three dissecting-room specimens for comparative analysis. Results: The collateral ligaments influenced the location of both hrMRI-determined bone oedema and bone erosion in early osteoarthritis. These changes were best understood in relation to the enthesis organ concept, whereby the interaction between ligament fibrocartilages leads to bone disease. Normal ligaments were commonly associated with microdamage at insertions corresponding to ligament thickening noted in early osteoarthritis. The ligaments also influenced the location of node formation in early osteoarthritis. The DIP extensor tendon insertions were associated with the development of a neoarticular surface. Conclusions: Small-joint collateral ligaments and tendons have a central role in the early stages of hand osteoarthritis, and determine the early expression of both the soft tissue and bony changes in disease.

Muscle plasticity after weight and combined (weight + jump) training

PURPOSE The purpose of this study was to compare the effects of jump training as a complement to weight training on jump performance and muscle strategy during the squat and countermovement jump. METHOD Twenty-two male handball players, between the ages of 17 and 24, and in good health, were randomly divided into three groups. Two were trained groups, weight training (WTG) and jump training combined with weight training (CTG), and one was a control group (CG). Maximal isometric force and maximal concentric power were assessed by a supine leg press, squat jump (SJ), counter movement jump (CMJ), and surface EMG was used to determine changes in muscle adaptation before and after the training period. RESULTS After 6-wk training programs, the two training groups increased maximal isometric force, maximal concentric power, and squat jump performance. However, only combined training presented a significant increase in height jump performance during the countermovement jump (P < 0.05). EMG analysis (as interpreted through the root mean square values) showed that the SJ was performed similarly before and after the training period for the two training groups. However, during the CMJ, only the CTG group adopted a new technique manifested by a short transition phase together with an increase in knee joint stiffness and knee extensor muscle activation and rectus femoris ratio. CONCLUSION It was suggested that the central activities in knee joint during the transition phase, in conjunction with intrinsic muscle contractile properties, play a major role in the regulation of performance during a CMJ. Furthermore, our study suggests that a change in maximal strength and/or explosive strength does not necessarily cause changes in combined movement such as the stretch shortening cycle.

Evidence for a distinctive pattern of bone formation in enthesophytes

Objectives: The mechanism of new bone formation at entheses in spondyloarthritis (SpA) is poorly understood, but it is a key factor contributing to disability in disease. As bony spur development is also an age-related phenomenon, spurs in elderly dissecting room cadavers were studied in order to establish general principles relating to their development. Methods: Spurs of different sizes were studied by routine histology at 26 different entheses (a total of 76 specimens) from the upper limb, lower limb and spine. The percentage of bone:marrow was compared in the posterior part of the calcaneus in cadavers with and without Achilles spurs to ascertain the relationship between spurs and immediately adjacent trabecular bone. Results: Bony spur formation was a common age related phenomena and typically occurred in the most fibrous part of an enthesis. Paradoxically, it was often heralded by the initial appearance of a thick zone of calcified fibrocartilage that subsequently developed bony nodules within it. Uncalcified fibrocartilage was more prominent around large spurs. Endochondral, intramembranous and chondroidal ossification all contributed to spur formation and growth, but cell hypertrophy and florid vascular invasion of a cellular calcified cartilage, typical of endochondral ossification, were not conspicuous features. Conclusion: Entheseal new bone formation occurs by a combination of three methods of ossification. However, endochondral ossification was atypical and differed from that seen in the normal development of cartilage bones or during fracture healing. How the inflammatory process modulates these processes could lead to a better understanding of entheseal new bone formation in SpA.

Regional variations in human patellar trabecular architecture and the structure of the proximal patellar tendon enthesis

Proximal patellar tendinopathy occurs as an overuse injury in sport and is also characteristic of ankylosing spondylitis patients. It particularly affects the posteromedial part of the patellar tendon enthesis, although the reason for this is unclear. We investigated whether there are regional differences in the trabecular architecture of the patella or in the histology of the patellar tendon enthesis that could suggest unequal force transmission from bone to tendon. Trabecular architecture was analysed from X‐rays taken with a Faxitron radiography system of the patellae of dissecting room cadavers and in magnetic resonance images of the knees of living volunteers. Structural and fractal analyses were performed on the Faxitron digital images using MatLab software. Regional differences at the enthesis in the thickness of the uncalcified fibrocartilage and the subchondral plate were evaluated histologically in cadaveric material. The radiological studies showed that the quantity of bone and the apparent trabecular thickness in the patella were greatest medially, and that in the lateral part of the patella there were fewer trabeculae which were orientated either antero‐posteriorly or superiorly inferiorly. The histological study showed that the uncalcified fibrocartilage was most prominent medially and that the subchondral plate was thinner laterally. Overall, the results indicate that mechanical stress at the proximal patellar tendon enthesis is asymmetrically distributed and greater on the medial than on the lateral side. Thus, we suggest that the functional anatomy of the knee is closely related to regional variations in force transmission, which in turn relates to the posteromedial site of pathology in proximal patellar tendinopathy.

Mesenchymal stem-cell potential in cartilage repair: an update.

Articular cartilage damage and subsequent degeneration are a frequent occurrence in synovial joints. Treatment of these lesions is a challenge because this tissue is incapable of quality repair and/or regeneration to its native state. Non‐operative treatments endeavour to control symptoms and include anti‐inflammatory medications, viscosupplementation, bracing, orthotics and activity modification. Classical surgical techniques for articular cartilage lesions are frequently insufficient in restoring normal anatomy and function and in many cases, it has not been possible to achieve the desired results. Consequently, researchers and clinicians are focusing on alternative methods for cartilage preservation and repair. Recently, cell‐based therapy has become a key focus of tissue engineering research to achieve functional replacement of articular cartilage. The present manuscript is a brief review of stem cells and their potential in the treatment of early OA (i.e. articular cartilage pathology) and recent progress in the field.