11
Muscle and Tendon Injuries
1. Recognize the macrostructure and microstructure of muscle and tendon.
2. Describe the two main types of muscle fibers.
3. Describe the three mechanisms for a muscle injury.
4. Describe the injury mechanism’s associated tendon pathology.
5. Name the functional unit of a tendon and its structural significance.
6. Describe the difference between a supraphysiologic and a subfailure load and how each type may contribute to an injury.
7. Define how a muscle strain differs from a ligament sprain.
8. Describe the differences between a tendonitis and a tendinopathy.
9. Describe the effects of aging on tendons.
10. Name and describe the three phases of connective tissue healing.
11. Describe the effects of immobilization on connective tissue.
12. Discuss clinical applications of therapeutic interventions based on the stages of connective tissue healing.
MUSCLE AND TENDON FUNCTIONAL ANATOMY
Macrostructure of Muscle and Tendons
Microstructure of Muscle
The muscle consists of muscle fibers and connective tissue (Fig. 11-1). There are three layers of connective tissue: the epimysium, the perimysium, and the endomysium. The epimysium surrounds the muscle and (along with the perimysium and the endomysium) is continuous with the muscle’s tendons. Within the muscle, groups of muscle fibers (known as a fasciculus) are surrounded by the perimysium. Within each fasciculus, each individual muscle fiber is surrounded by the endomysium.
A muscle fiber (muscle cell) is further divided into myofibrils and myofilaments (see Fig. 11-1). Each muscle fiber is surrounded by a sarcolemma, the muscle fiber’s cellular membrane. Within the muscle fiber, the myofibrils are contained within the sarcoplasm. The myofibrils are bundles of the contractile proteins myosin and actin grouped together as a sarcomere (the basic functional unit of the myofibril). The interaction between the myosin and actin during the muscle’s contraction contributes to functional movement. The structural relationship between the contractile and noncontractile components allows skeletal muscles to perform both concentric (shortening) and eccentric (lengthening) muscle contractions as well as the ability to return to a resting position.18
Muscle Fiber Types
Whereas the type I (ST) muscle fibers possess a high endurance capacity, the type II (FT) muscle fibers differ in that they are specialized for more anaerobic activities. There are several types of FT fibers that are differentiated by their resistance to fatigue, their functional use, and the type of myosin heavy chain (MHC) protein complex present (Table 11-1).27
Table 11-1
Parameter | Type I | Type IIA | Type IIB |
Cell body size | Small | Medium | Large |
Conduction velocity | Slow | Fast | Fast |
Number of muscle fibers | Few | More | Most |
Rate of force development | Slow | Moderate | Fast |
Absolute force generation | Low | Moderate | High |
Resistance to fatigue | High | Moderate | Low |
Mitochondrial density | High | High | Low |
Aerobic capacity | High | Moderate | Low |
Myoglobin content | High | Low | Low |
Within the literature, there are at least eight types of named muscle fibers: I, IC, IIA, IIB, IIC, IID, IIX (IIB), and IIAX.7,9,12,15,27,30,31,35 However, this does not mean that there are eight distinct fiber types. Rather, there appears to be an inconsistency in the literature as to how the fibers are named.7,9,12,15,27,30,31,35 While the PTA can appreciate that there is variability among sources about the actual number of different fiber types, it is more important to appreciate the two broad categories of muscle fibers: type I and type II. Type I are the slow, oxidative fibers and type II are the fast, glycolytic fibers. There are significant differences between the two main types that have functional implications. The exercise prescription strategy used during different phases of the healing process should take into account the primary fiber composition of the injured skeletal muscle. The characteristics of the three most common fiber types in human skeletal muscle characteristics—types I, IIA, and IIB—will be compared in this chapter (see Table 11-1).7,31,35
Microstructure of Tendon
Tendons are dense connective tissue consisting of fibroblasts (cells) and an extracellular matrix composed of collagen fibers, elastin, and ground substance (Fig. 11-2). The fibroblasts are responsible for synthesizing components of the extracellular matrix.28 The ground substance provides support to collagen fibers.28 The collagen fibers, which are oriented in a parallel arrangement, provide strength to resist tensile forces.
The structural hierarchy of tendons is similar to skeletal muscle. Collagen fibrils are grouped together into the tendon’s basic functional unit, the collagen fiber. Groups of collagen fibers (primary fiber bundle) form a subfascicle.16 Several subfascicles grouped together form a fascicle (secondary fiber bundle).16 Several fascicles grouped together form a tertiary bundle.16 These three groups (bundles) are surrounded by a connective tissue called the endotenon.16 The epitenon surrounds the entire tendon as a fine, loose connective tissue sheath.16,28 Blood vessels and nerves are also contained within the epitenon.28 The paratenon is a loose areolar connective tissue attaching to the outer portion of the epitenon.16,28 The function of the paratenon is to allow gliding over adjacent structures.16
The transition from tendon into its osseous attachment site includes several connective tissue changes.16 The first change is from the primary tendon structure into fibrocartilage. Next, the fibrocartilage converts into a mineralized fibrocartilage. The mineralized fibrocartilage secures the attachment of the tendon to the bone. In addition to this arrangement, there are collagen fibers from the tendon that pass through these transition zones and attach to the bone. These fibers are known as Sharpey’s fibers.
MUSCLE AND TENDON INJURIES
Examples from the world of sports will help illustrate the significant loads and stresses that may be experienced by some athletes. During the deceleration phase of pitching a baseball, the pitcher’s shoulder rotates up to 7000° per second with 400 newtons (N) of posterior shear forces, 300 N of inferior shear forces, and 1000 N of compressive forces experienced at the glenohumeral joint (Fig. 11-3, A).20 Over time, these shear and compressive forces may increase the baseball pitcher’s risk of sustaining a shoulder injury.20,21,34 During the golf swing, a golfer may experience compressive loads in the lumbar spine that are eight times his or her body weight (Fig. 11-3, B).11 To provide some perspective, a distance runner will experience compressive loads that are equal to three times his or her body weight during the run. To reduce the risk of injury, muscles and tendons must possess the ability to stretch or deform in response to the applied load. When an applied load supersedes the muscle or tendon’s ability to resist tensile forces, the muscle or tendon is at a higher risk of injury.