Tendon Structure

and Healing

Tendon
A unit of musculoskeletal tissue that transmits
force from muscle to bone1
The functional link between the dynamic and
the static part of the musculoskeletal system
transferring
muscle contraction to the skeletal system and
thus leading to motion
Composed predominately of collagen fibers and
rod- or spindle-shaped fibroblast-like cells
(tenocytes)
Collagen constitutes the basic structural unit of
tendon
1. James R, Kesturu G, Balian G, Chhabra B. Tendon: Biology, Biomechanics, Repair,
Growth
Factors, and Evolving Treatment Options J Hand Surg 2008;33A:102112

Composition ofTendons

(Kjaer,2004)

Structure of Tendon
High amount of collagen (70% of dry weight) and parallel
fibre orientation account for high tensile strength the
greatest in our body
Type I collagen is the predominate type of collagen (95 %),
the other 5% from type III and V and glycosaminoglycan.
The collagen forms fibrils, organized into bundles with
nerves and blood vessels covered by epitenon and
paratenon
Small amount of synovial fluid aids in motion smoothness

Structure of Tendon
TENDON CELLS (TENOCYTES)
Specialized fibroblast cells within the tendon
The primary role of tenocytes :
Control tendon metabolism (production and
degradation of the Extracellular Matrix)
Respond to the mechanical stimuli applied to the
tendon mechanotransduction
EXTRACELLULAR MATRIX (ECM)
Largely composed of a network of collagen fibers.
Primary function is to maintain the tendons structure and
facilitate the biomechanical response to mechanical
loading

Structure of Tendon
COLLAGEN
Synthesized by tenocytes
The collagen network is dominated by type I fibers
(60%)
Combine to form ordered units of microfibrils (5 collagen
molecules), subfibrils, and fibrils
Proteoglycans and glycoproteins binding the fibrils
together to form fascicles
ELASTIN
Composes approximately 2% of the dry weight of
tendon
Elastin fibers and several glycoproteins are also integral
parts of tendon ECM and provide functional stability to
the collagen fibers

Macrostructure

Schematic representation of the

microarchitecture of a tendon

Structure of Tendon
GROUND SUBSTANCE
Composed mainly of inorganic substances
and other proteins.
The inorganic substances:
Proteoglycans (PGs)
Sulfated polysaccharide chains
(glycosaminoglycans)
Hyaluronic acid (HA) chain
Glycoproteins
and several other small molecules

Structure of Tendon
Endotenon
Thin reticular network of connective tissue
investing each tendon fiber
Contains the vascular, lymphatic, and neural
transmission routes to maintain tendon
fibroblasts

Epitenon
Loose connective-tissue sheath containing the
vascular, lymphatic, and nerve supply to the
tendon
Binds the fascicles together

Tendon Types
Paratenon-covered (e.g. patellar, achilles)
Loose areolar connective tissue (paratenon)
Majority of tendons (move in a straight line)
Rich vascular supply

Sheathed (e.g. hand flexor tendons)

Tendons that bend sharply
Sheath acts as a pulley and directs tendon path
Sliding is assisted by synovial fluid (parietal
synovial membrane and from the visceral
synovial membrane or epitenon)
Less vascularized and have avascular areas
that receive nutrition by diffusion

Blood supply
Paratenon-covered tendons
Perimysium
Paratenon / mesotenon
Periosteal insertion

Tendons in sheaths:
Synovial diffusion in avascular regions
Osseous insertions
Proximal mesotenon via vinculae

Vascularity
Tendon with sheath

Tendon without sheath

Vascular supply through the

vinculum longus

Vessels enter from many points

on the periphery and
anastomose with a longitudinal

VINCULAE

Nerve Supply
No nerve fibres within tendon body
Epitenon and peritenon contain
nerve endings (sensory)
Golgi tendon organs at musculotendinous junction (proprioceptive)

Biomechanics
Tendon possesses one of the highest tensile
strengths of any soft tissue in the body.
High mechanical strength, good flexibility,
and an optimal level of elasticity
The tensile properties characterized by:
The mechanical properties (stress-strain
relationship) of the collagen
The structural properties (load-elongation
relationship) of the bone-tendon-muscle structure

At rest, collagen fibers and fibrils display a

crimped configuration

Stress-strain Curve of Normal

Tendon

Biomechanics
Very high loads are placed on human
Achilles tendon during running is 9
kN, corresponding to 12.5 times body
weight
Tendons are at the highest risk for
rupture if tension is applied quickly
and obliquely

Factors Affecting the Mechanical

Properties of Tendons

Age
Anatomic location
Exercise and immobilization
Heat treatment
Pregnancy
Comorbidities (diabetes mellitus, connective
tissue disorders, renal disease)
Pharmacologic agents (steroids, nonsteroidal
anti-inflammatory drugs or NSAIDs)

Factors Affecting the Mechanical

Properties of Tendons
Age
Tenocytes decrease in number and flattened and
reduced capability for the mechanotransduction for
collagen production and maturation

Anatomic location
Tensile strength of the digital flexor tendons twice
as large as the digital extensor tendons collagen
concentration

Exercise and immobilization

Immobilization stress deprivation decrease in
collagen synthesis and an increase in matrix
metalloproteinases (MMPs) reduces the
mechanical properties of the tissue

Factors Affecting the Mechanical

Properties of Tendons
Heat treatment
Significant tendon shrinkage after laser
treatment tensile testing shortened 10% of
their resting length showed a decrease in load
to failure to approximately one third

Pregnancy
Increased laxity of the tendons and ligaments
in the pubic area during later stages of
pregnancy and the postpartum period
hormone relaxin

Factors Affecting the Mechanical

Properties of Tendons
Comorbidities
Diabetes Melitus
Changes in connective tissue and the metabolic
fluctuations microvascularity and promote
collagen accumulation in periarticular tissues

Connective Tissue Disorders

Rheumatologic conditions (e.g., rheumatoid
arthritis, spondyloarthropathies)
inflammatory infiltrate that promotes the
destruction of collagenous tissue

Renal Disease
Increase in the amount of elastin and collagen
destruction

Factors Affecting the Mechanical

Properties of Tendons
Pharmacologic agents
Steroids
Inhibition of collagen synthesis altered
healing and a decrease on the peak load of
these tissues

Fluoroquinolones
Cause an increase in the activity of matrix
metalloproteinases (MMPs)

TENDON INJURIES

Tendon Injuries
Direct trauma
Laceration or contusion
Sharp tools
Special importance to the hand and
upper extremity

Indirect trauma
Tensile overload
Multifactorial (anatomic location,
vascularity, and skeletal maturity,
magnitude of the forces)

Incidence
An acceleration-deceleration
mechanism has been reported in up
to 90% of sports-related Achilles
tendon ruptures
Degenerative tendinopathy is the
most common finding in spontaneous
tendon ruptures

Healing process
Healing process in a paratenoncovered tendon
Healing process in sheated tendon

Phases of tendon healing

Healing in Paratenon-Covered
Tendon
Immediate

Blood cell
Inflammatory products
Fibrin
Nuclear debris

1st week

Proliferating tissue from paratenon

Granulation
Undifferentiated and disorganised fibroblasts
tissue
Capillary buds
Collagen synthesis

Healing in Paratenon-Covered
Tendon
2nd weeks
Stumps fused by fibrous
bridge
Fibroblast proliferation
Collagen production
Fibrils accumulate
perpendicular to long axis
Vascular proliferation in
stumps
Fibrovascular tissue from
paratenon blends with
epitenon to form tendon
callus

Healing in Paratenon-Covered
Tendon
3-4 weeks
Fibroblasts and collagen fibers
Rorientation & Organisation

> 4 weeks

Tensile properties increase

Remodelling and further organisation
Minimal histological difference by 20 weeks
Months to regain full strength

Healing in Sheathed Tendon

Healing of these tendons has been a
controversial topic
Early data suggest: Healing by granulation
from tendon sheath
- Fibroblasts derived from the tendon sheath and
surrounding tissues invade the healing site
and initiate, regeneration
- Tendon cells played no active role

Recent data suggest

Tenocytes have intrinsic repair capabilities
Proliferation and cell migration at tendon ends
from epitenon and endotenon

Healing in Sheathed Tendon

3 weeks
Cells from the epitenon migrated into the wound
site via desmosome phagocytes or macrophages
Cell from endotenon increased protein synthesis

6 weeks
Number of phagocytes within the repair site had
increased

9 weeks
Cellular activity at repair site continued
Extracellular matrix of collagen fibrils in various
stages
Remodeling process phagocytosis and collagen
synthesis.

Healing in Sheathed Tendon

Repaired tendons
treated
Controlled passive
motion intrinsic
response epitenon
predominates
Immobilized tendon
ingrowth of connective
tissue from the digital
sheath and cellular
proliferation of the
endotenon

Tendon Repair
Factor determines quality of tendon
repair
Suture material
Type of suture repair
Knotting of sutures
Continuous passive motion
Weightbearing
Nature and location

Tendon Repairs
Suturing technique
Passed perpendicular to the tendon
before passing it across the injury,
parallel to the tendon stronger
tendon-suture-tendon constructs
Minimize gap formation between the
tendon stumps

Tendon Repairs
Predicting the success of tendon repair
gliding function after injury
Large scar or adhesion formation
detrimental to the gliding function
Early weightbearing / early active
mobilization rupture and gap formation
Carefully controlled early passive
mobilization stimulates repair and
improves strength in the first few months

Tendon Transfer
Indications:
Peripheral nerve injury
Replacement of ruptured tendons in rheumatoid
patients
Central nervous system disorders such as cerebral
palsy

Considerations for transfer

Absence of inflammation and edema

Mobility of the joints
Adequacy of the tissue bed
Adequacy of skin coverage
Potential for an effective line of action of the
transferred tendon

Tendon Transfer
Postoperatively long and rigorous
rehabilitation desired joint motion

Adhesions Formation
Lack of mechanical stimulus
proliferation of scar tissue and
subsequent adhesions impede
normal tendon function
Mechanical loading associated with
motion of the healing tendon
decreases formation of postoperative
adhesions and increases the strength

Adhesions Formation
Many attempts have been made to
reduce adhesion formation
Materials
Mechanical barriers such as polyethylene
or silicone
Pharmacological agents such as
indomethacin and ibuprofen, hyaluronate,
5-fluorouracil
no significant differences in adhesion
formation in a rat Achilles tendon model

Rehabilitation
After the inflammatory phase,
controlled stretching
Increase collagen synthesis by tenocytes
and improve fiber alignment

Higher tensile strength

Immobilization results in tendon
atrophy

Summary
There are many factors affecting the mechanical
properties of tendons
Tendon healing process consist of 4 phases
Regain most of original strength by 21-28 days

Early mobilisation Increases ROM but can

decrease tendon repair strength
Controlled stretching can be done after the inflammatory
phase

Adhesion formation may impede normal tendon

function
Many attempts have been made to reduce
adhesion formation no significant result

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