Stress fracture sites related to underlying bone health in athletic females.

OBJECTIVE: The study tested the hypothesis that females who sustain stress fractures of cancellous bone have decreased bone density. DESIGN: A retrospective, controlled, cross-sectional study. SETTING: The setting of the study was a tertiary care center for Women's Sports Medicine. PATIENTS: 20 female patients under the age of 40 who had suffered a stress fracture and who had a positive diagnostic study (radiograph, bone scan, or magnetic resonance imaging) were included in the study. INTERVENTIONS: Patients who had a positive diagnostic study (radiograph, bone scan, or magnetic resonance imaging) for the diagnosis of stress fracture also underwent dual energy X-ray absorptiometry (DEXA) scans. MAIN OUTCOME MEASURE: Bone density measured by the DEXA scan, as defined by the World Health Organization criteria for osteopenia (greater than one standard deviation from the standard age-matched control). RESULTS: 8 of 9 patients with cancellous stress fractures had DEXA scans indicating osteopenia while only 3 of 11 patients with stress fractures of cortical bone had a scan indicating osteopenia (p = 0.01). CONCLUSIONS: A cancellous stress fracture in a female may be a warning sign of early onset osteopenia. We recommend that young females who have documented stress fractures of cancellous bone or cortical bone (with risk factors for osteopenia) undergo bone density evaluation.

The effect of cytokines on the migration of fibroblasts derived from different regions of the canine shoulder capsule.

This study examined the effect of several cytokines on the chemotactic migration of fibroblasts derived from 3 different parts of the canine shoulder: the upper part of the medial glenohumeral ligament (equivalent to the anterior part of the inferior glenohumeral ligament of the human shoulder); the inferior part of the medial glenohumeral ligament (equivalent to the axillary pouch of the human shoulder); and the posterior capsule (equivalent to the thin posterior capsule in the human shoulder). Platelet-derived growth factor-AB stimulated the migration of all 3 cell types in a dose-dependent manner, with increases from 150% to 300% at 1 ng/mL to 500% to 700% at 10 ng/mL. Hepatocyte growth factor also stimulated the migration of all 3 cell types in a dose-dependent manner (130% to 310%). Insulinlike growth factor-1 increased the migration of all 3 types of fibroblasts by 160% to 250%. Bone morphogenic protein-2, interleukin-1, and transforming growth factor-b had no significant effect on migration of shoulder capsular fibroblasts. These data demonstrate that capsular fibroblasts are responsive to specific growth factors and suggest the potential for use of growth factors to augment healing and/or remodeling of the shoulder capsule.

Insulin-like growth factor-I is expressed by avian flexor tendon cells.

Cells in normal tendon are in a resting G0 state, performing maintenance functions. However, traumatic injury introduces growth factors such as platelet-derived growth factor and insulin-like growth factor from blood as well as activates endogenous growth factors. These factors stimulate migration and proliferation of tendon cells at the wound area. Tendon cells require growth-promoting factors to transit the cell cycle. To evaluate the contribution of endogenous growth factors in tendon, extracts of the epitenon and internal compartment of avian flexor tendon as well as medium of cultured cells from the epitenon (tendon surface cells) and internal tendon (tendon internal fibroblasts) were collected to assess their ability to stimulate DNA synthesis. Acid-ethanol extracts of tissues and medium were chromatographed on a P-30 molecular sieve column and assayed for mitogenic activity by quantitating [3H]thymidine incorporation into tendon cell DNA. The extract from the internal tendon compartment was more stimulatory for DNA synthesis than that from the epitenon, particularly when tested on tendon internal fibroblasts. However, conditioned medium fractions from surface epitenon cells stimulated DNA synthesis to a high degree on both tendon surface cells and tendon internal fibroblasts. Conditioned medium from tendon internal fibroblasts was also stimulatory. An anti-insulin-like growth factor-I antibody ablated most of the mitogenic activity present in both tissues and conditioned medium. The levels of acid-extractable insulin-like growth factor-I in tendon were determined by competitive radioimmunoassay as 1.48+/-0.05 ng/g tissue for the epitenon and 3.83+/-0.03 ng/g tissue for the internal compartment. Results of Western immunoblots of conditioned medium revealed insulin-like growth factor-I at the 7.5 kDa position. Cultured tendon surface cells and tendon internal fibroblasts as well as cells in intact flexor tendon expressed insulin-like growth factor-I mRNA detected by reverse transcriptase-polymerase chain reaction. In situ hybridization histochemistry positively identified insulin-like growth factor-I mRNA in tendons from 52-day-old chickens. Platelet-derived growth factor was not detected at the protein or message levels. Furthermore, tendon surface cells and tendon internal fibroblasts both expressed receptors for insulin-like growth factor-I detected by flow cytometry. These data suggest that tendon cells express insulin-like growth factor-I mRNA and synthesize insulin-like growth factor-I in both the epitenon and the internal compartment of tendon, which is present in an inactive form, most likely bound to insulin-like growth factor-binding proteins.

The effect of ciprofloxacin on tendon, paratenon, and capsular fibroblast metabolism.

The pathologic mechanisms underlying fluoroquinolone-induced tendinopathy are poorly understood. The observed incidence of tendinitis and tendon rupture in patients treated with ciprofloxacin hydrochloride suggests that the fluoroquinolone antibiotics alter tendon fibroblast metabolism. The purpose of this study was to examine the effect of ciprofloxacin on fibroblast metabolism in vitro. Canine Achilles tendon, paratenon, and shoulder capsule specimens were maintained in culture with ciprofloxacin (5, 10, or 50 microg/ml). Fibroblast proliferation, collagen synthesis, proteoglycan synthesis, and matrix-degrading activity were analyzed. Incubation of Achilles tendon, Achilles paratenon, and shoulder capsule fibroblasts with ciprofloxacin resulted in a statistically significant 66% to 68% decrease in cell proliferation compared with control cells at day 3 in culture. Ciprofloxacin caused a statistically significant 36% to 48% decrease in collagen synthesis compared with controls in all fibroblast cultures. Ciprofloxacin caused a statistically significant 14% to 60% decrease in proteoglycan synthesis in all fibroblast cell lines. Compared with unstimulated control fibroblasts, culture media from Achilles tendon, paratenon, and shoulder capsule cells that were exposed to ciprofloxacin demonstrated statistically significant increases in matrix-degrading proteolytic activity after 72 hours in culture. This study demonstrates that ciprofloxacin stimulates matrix-degrading protease activity from fibroblasts and that it exerts an inhibitory effect on fibroblast metabolism. The increase in protease activity and the inhibition of both cell proliferation and the synthesis of matrix ground substance may contribute to the clinically described tendinopathies associated with ciprofloxacin therapy.

Adhesive capsulitis. A treatment approach.

Adhesive capsulitis of the shoulder is a condition of unknown etiology that results in the development of restriction of active and passive glenohumeral motion. The authors will review what currently is known about the etiology of idiopathic adhesive capsulitis, will raise unanswered questions regarding etiology and treatment, and will define a stage-based evaluation and treatment program. Treatment options including benign neglect, home-based and supervised physical therapy, intraarticular corticosteroid injections, closed manipulations, and arthroscopic capsular release will be reviewed critically and the authors' approach to the treatment of patients with idiopathic adhesive capsulitis also will be presented. Additionally, areas of future research will be defined.

Multidirectional instability of the shoulder in the female athlete.

Multidirectional instability (MDI) of the shoulder is a complex entity, characterized by symptomatic global laxity of the glenohumeral joint. Because symptoms vary widely, making the diagnosis of MDI is not always straightforward. In addition, relatively few series of patients with this disorder have been reported. Thus, precise definition, causes, and treatment remain elusive. This article reviews the current literature regarding anatomy, biomechanics, clinical diagnosis, and treatment of MDI that are relevant to care of the female athlete.

Differential expression of integrin subunits in canine knee ligament fibroblasts.

A method for measuring the expression of integrin subunits on the cell surface of knee ligament fibroblasts was developed with use of flow cytometry and immunofluorescence. The ligament cells exhibited uniform size and density, as shown by forward and side-scatter properties, and showed minimal nonspecific binding of isotype control antibodies compared with unstained cells. All cells expressed the alpha5 integrin subunit; lateral collateral ligament cells stained with antibody to alpha5 showed a mean fluorescence intensity 2-fold higher than that of medial collateral ligament cells, 1.5-fold higher than that of posterior cruciate ligament cells, and 3-fold higher than that of anterior cruciate ligament cells, indicating a greater expression of the alpha5 subunit by lateral collateral ligament cells than by medial collateral, posterior cruciate, and anterior cruciate ligament cells. All cells expressed the beta1 integrin subunit; the expression by posterior cruciate ligament cells was 3-fold higher than that by medial collateral ligament or lateral collateral ligament cells and 5-fold higher than that by anterior cruciate ligament cells. All cells expressed the beta3 integrin subunit; the expression by posterior cruciate ligament cells was 1.5, 3, and 4.5-fold greater than that by lateral collateral, anterior cruciate, and medial collateral ligament cells, respectively. Our data suggest there is a differential expression of integrin subunits in knee ligament fibroblasts, and this in part may explain differences in their attachment and adherence to extracellular matrix molecules.

The effect of cytokines on the proliferation and migration of bovine meniscal cells.

We determined the effect of cytokines on the proliferation and migration of cells isolated from the inner-third (white-white), middle-third (red-white), and outer-third (red-red) regions of bovine meniscus. Cells from the outer, or peripheral, region of the meniscus exhibited higher DNA synthesis in the presence of 10% serum compared with cells from the inner or central regions. Recombinant human platelet-derived growth factor-AB, hepatocyte growth factor/scatter factor, and bone morphogenic protein-2 stimulated DNA synthesis of all meniscal cells in a dose-dependent manner, with a two- to threefold maximal stimulation at 10 ng/ml. Cell migration was also stimulated by addition of cytokines. Platelet-derived growth factor and hepatocyte growth factor caused an increase in the migration of cells derived from all three zones, while interleukin-1 selectively stimulated the migration of outer-zone meniscal cells. Epidermal growth factor was much less effective and stimulated the migration of cells in the inner and outer zones by 40% to 50%, while bone morphogenic protein-2 and insulin-like growth factor-1 stimulated the migration of meniscal cells from the middle zone by 40% to 50%. The identification of cytokines that stimulate both the growth and migration of meniscal cells may provide new tools for modulation of meniscal healing.

Characterization of chemotactic migration and growth kinetics of canine knee ligament fibroblasts.

Migration and proliferation of ligament fibroblasts are essential for the healing of ligament injuries. This study was designed to evaluate the migration of intraarticular (anterior and posterior cruciate) and extraarticular (medial and lateral collateral) ligament fibroblasts in response to cytokines and to determine the effect of cell passage on cell proliferation. Recombinant human platelet-derived growth factor, hepatocyte growth factor/scatter factor, and bone morphogenic protein-2 stimulated the migration of all ligament cells in a dose-dependent manner, with optimal migration at 10 ng/ml. Recombinant human epithelial growth factor preferentially stimulated the migration of intraarticular ligament fibroblasts, whereas recombinant human interleukin-1 was more effective with extraarticular ligament fibroblasts. Recombinant human insulin-like growth factor-1, insulin-like growth factor-2, transforming growth factor-beta, and fibroblast growth factor had no significant effect on the migration of ligament-derived fibroblasts. These data suggest that specific cytokines stimulate the migration of knee ligament fibroblasts and provide a rationale for possible therapeutic approaches to optimize ligament healing. Fibroblasts derived from the anterior cruciate ligament have been shown to proliferate at a slower rate than those derived from the medial collateral ligament. We have extended these observations and have demonstrated that fibroblasts from both the posterior and anterior cruciate ligaments proliferate at a slower rate than lateral and medial collateral ligament-derived fibroblasts. The differences between the growth rates of intraarticular and extraarticular fibroblasts become insignificant with serial passaging of the cells.

Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging.

The purpose of this study was to demonstrate that specialized magnetic resonance imaging provides an accurate assessment of lesions of the articular cartilage of the knee. Arthroscopy was used as the comparative standard. Eighty-eight patients who had an average age of thirty-eight years were evaluated with magnetic resonance imaging and subsequent arthroscopy because of a suspected meniscal or ligamentous injury. The magnetic resonance imaging was performed with a specialized sequence in the sagittal, coronal, and axial planes. Seven articular surfaces (the patellar facets, the trochlea, the femoral condyles, and the tibial plateaus) were graded prospectively on the magnetic resonance images by two independent readers with use of the 5-point classification system of Outerbridge, which was also used at arthroscopy. Six hundred and sixteen articular surfaces were assessed, and 248 lesions were identified at arthroscopy. Eighty-two surfaces had chondral softening; seventy-five, mild ulceration; fifty-three, deep ulceration, fibrillation, or a flap without exposure of subchondral bone; and thirty-eight, full-thickness wear. To simplify the statistical analysis, grades 0 and 1 were regarded as disease-negative status and grades 2, 3, and 4 were regarded as disease-positive status. When the grades that had been assigned by reader 1 were used for the analysis, magnetic resonance imaging had a sensitivity of 87 per cent (144 of 166), a specificity of 94 per cent (424 of 450), an accuracy of 92 per cent (568 of 616), a positive predictive value of 85 per cent (144 of 170), and a negative predictive value of 95 per cent (424 of 446) for the detection of a chondral lesion. Interobserver variability was minimum, as indicated by a weighted kappa statistic of 0.93 (almost perfect agreement). With use of this readily available modified magnetic resonance imaging sequence, it is possible to assess all articular surfaces of the knee accurately and thereby identify lesions that are amenable to arthroscopic treatment.

Effects of exercise on Achilles tendon healing in a rat model.

The effects of motion, or lack of it, on Achilles tendon healing are not well defined. We have recently shown that immobilization has a detrimental effect on tendon healing in a rat model. The aim of this experiment was to determine whether enforced exercise had an additional beneficial effect on the mechanical and functional recovery of divided Achilles tendons in rats. Male Sprague-Dawley rats were randomly allocated into a nonexercise and an exercise group (N = 10 for each group). In both groups the right Achilles tendon was surgically transected. The left, uninjured lower limb served as an internal control. Both groups of animals were housed under identical conditions with the exception that the exercise group swam for 15 minutes per day. Functional performance was determined from the measurement of hindpaw prints of walking rats preoperatively and on alternate postoperative days. On day 15, the animals were killed and weighed, and biomechanical evaluations were performed on both the injured and uninjured Achilles tendon constructs. There were no differences in weight at time of death. All animals had an initial functional deficit that returned to near-normal by day 15. There were significant differences in the morphological and the mechanical properties of the healing Achilles tendon constructs at day 15 when comparing the injured with the uninjured Achilles tendon constructs. Supplemental exercise, however, had no effect on the functional or mechanical recovery of injured or uninjured Achilles tendons in the rat model.

Articular contact patterns of the normal glenohumeral joint.

The purpose of this study was to determine the articular contact patterns of the normal glenohumeral joint, and to correlate these findings with cartilage and subchondral bone architecture. We studied 10 normal shoulders of cadavers. We removed all soft tissues except the joint capsule and rotator cuff and then placed the shoulders on a testing apparatus that allowed freedom of translation in three planes. After the humerus was placed in a neutral position of rotation, articular contact patterns were measured with specially prepared prescale Fuji film so that it could be inserted between the joint surfaces. Articular contact was analyzed with 222 and 444 N of joint compressive load, and the humerus was positioned in scapular plane abduction of 0 degree, 45 degrees, and 90 degrees. The contact patterns were then digitized to determine percentage contact of the humeral head on the glenoid. We studied 12 additional cadaver shoulders with fine microradiographs and histologic techniques after we sectioned the glenoids in the anterior-posterior and superior-inferior planes. We then analyzed articular and subchondral architecture. We found that when the shoulder was adducted the contact area of the humeral head on the glenoid was limited to the anatomic region of the central glenoid known as the "bare area." This was histologically and radiographically an area of cartilage thinning and increased subchondral bone density. As the shoulder was abducted the articular congruity and percentage contact area increased. We concluded that there was a slight articular mismatch with the shoulder adducted in the normal shoulder. Histologic and radiographic studies suggested that the central bare area region of the glenoid was a region of increased compressive loading. As the shoulder was abducted the joint became more congruent and thus the contact area of the humeral head on the glenoid increased.

Immunolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder.

The purpose of this study was to test the hypothesis that specific cytokines are involved in the initiation and evolution of the fibrotic process in adhesive capsulitis of the shoulder. After approval from the Institutional Review Board, biopsies of shoulder capsule and synovium were collected during shoulder arthroscopy from 19 patients with adhesive capsulitis, 14 patients with nonspecific synovitis and no fibrosis or clinical evidence of adhesive capsulitis, and seven patients undergoing surgery for another pathology who had a normal capsule and synovium. Immunohistochemical localization with monoclonal antibodies to transforming growth factor-beta and its receptor, platelet-derived growth factor and its receptor, basic fibroblast growth factor, interleukin-1 beta, tumor necrosis factor-alpha, and hepatocyte growth factor was performed using standard immunoperoxidase techniques. The frequency of cytokine staining was correlated with the clinical diagnosis. Synovial cells, fibroblasts, T-cells, and B-cells were identified with specific antibodies, and newly synthesized matrix was examined for type-I and type-III collagen by immunohistochemical staining. The predominant cell types present were synovial cells and fibroblasts. Staining for type-III collagen in adhesive capsulitis tissues indicated new deposition of collagen in the capsule. There was staining for transforming growth factor-beta and its receptor, platelet-derived growth factor and its receptor, interleukin-1 beta, and tumor necrosis factor-alpha in adhesive capsulitis and nonspecific synovitis tissues, compared with minimal staining in normal capsule. Staining was more frequent in synovial cells than in capsular cells. The frequency of cell and matrix staining for transforming growth factor-beta, platelet-derived growth factor, and hepatocyte growth factor was greater in adhesive capsulitis tissues than in those from patients with nonspecific synovitis. No difference in the frequency of staining between primary (idiopathic) and secondary adhesive capsulitis was found. The results of this study indicate that adhesive capsulitis involves both synovial hyperplasia and capsular fibrosis. Cytokines such as transforming growth factor-beta and platelet-derived growth factor may be involved in the inflammatory and fibrotic processes in adhesive capsulitis. Matrix-bound transforming growth factor-beta may act as a persistent stimulus, resulting in capsular fibrosis. Understanding the basic pathophysiology of adhesive capsulitis is an important step in the development of clinically useful antifibrotic agents that may serve as novel treatments for patients with this conditions.

Modulation of tendon healing by nitric oxide.

Nitric oxide (NO) is a small, diffusible free radical that is generated from L-arginine by a family of enzymes, collectively termed the nitric oxide synthases. We investigated the role of NO in tendon healing. NO synthase activity and immunoreactivity was absent in un-injured rat Achilles tendon. After surgical division there was a five-fold increase in NO synthase activity and immunoreactivity within the healing tendon at day 7, with a return to near baseline levels at day 14. Inhibition of NO synthase activity with oral administration of N omega-nitro-L-arginine methyl ester (L-NAME) resulted in a significant reduction in cross-sectional area (30% at day 7, p < 0.01, 50% at day 15, p < 0.001) and failure load (24% at day 7, p < 0.01) of the healing Achilles tendon constructs. Rats fed the same regimen of the enantiomer of L-NAME, (D-NAME) had normal tendon healing. These results indicate that nitric oxide synthase is induced during tendon healing and inhibition of nitric oxide synthase inhibits this tendon healing.

Intracellular calcium response of ACL and MCL ligament fibroblasts to fluid-induced shear stress.

This study examines the real-time intracellular calcium concentration, [Ca2+]i, response of canine medial collateral ligament (MCL) and anterior cruciate ligament (ACL) fibroblasts subjected to a fluid-induced shear stress of 25 dynes/cm2. In experiments using a modified Hanks' Balanced Salt Solution (HBSS) perfusate, both cell types demonstrated a significant increase in peak [Ca2+]i compared to respective no-flow controls, the response of MCL fibroblasts being nearly 2-fold greater than that of ACL fibroblasts. In studies where the cells were bathed in a medium of HBSS supplemented with 2% newborn bovine serum (NBS) and then introduced to flow with the same medium, ACL fibroblasts responded nearly 3-fold greater than MCL fibroblasts. Neomycin (10 mM), thapsigarigin (1 microM) and Ca(2+)-free media supplemented with EGTA (1 mM) were able to inhibit significantly the [Ca2+]i response to flow with HBSS in both fibroblasts. Thapsigargin also blocked the NBS flow response in both cell types, while neomycin and Ca(2+)-free media significantly inhibited the ACL response. Our findings demonstrate that ACL and MCL cells are not the same. These differences may be related to the disparate healing capacity of the ACL and MCL observed clinically.

Nitric oxide: an important articular free radical.

Nitric oxide is a small molecule that is synthesized by a family of enzymes, the nitric oxide synthases, and is overproduced in rheumatoid arthritis and osteoarthrosis. The aim of this investigation was to elucidate the potential sources of nitric oxide in joint tissues and to determine if the production of nitric oxide could be inhibited by dexamethasone or methotrexate, two agents that inhibit other forms of inducible nitric oxide synthase. Methotrexate inhibits the synthesis of biopterin, which is a co-factor for nitric oxide synthase. Explants of human and bovine cartilage and cultured chondrocytes released large amounts of nitrite, the stable end product of nitric oxide, when stimulated with endotoxin, interleukin-1 beta, or tumor necrosis factor-alpha. The production of nitrite was time-dependent and endotoxin, interleukin-1 beta, and tumor necrosis factor-alpha dose-dependent and was inhibited by the nitric-oxide-synthase inhibitors N omega-nitro-L-arginine methyl ester and aminoguanidine. The inducible nitric oxide synthase in bovine chondrocytes was calcium-dependent and was inhibited by high concentrations of methotrexate or dexamethasone. No constitutive nitric-oxide-synthase activity and little or no inducible nitric-oxide-synthase activity were demonstrable in explants or cell cultures derived from menisci. Fresh explants of bovine articular synovial tissue constitutively released nitrite that was inhibited by N omega-nitro-L-arginine methyl ester, but the release could not be enhanced by endotoxin, interleukin-1 beta, or tumor necrosis factor-alpha. There was no constitutive or inducible production of nitrite by explants or cells derived from the synovial tissue or shoulder capsule of a human or by explants or cells derived from canine anterior cruciate, posterior cruciate, medial collateral, lateral collateral, or patellar ligaments. Taken together, these results indicate that chondrocytes represent the major source of inducible nitric oxide synthase and nitric oxide during inflammation or infection of a joint.

How I Manage Tennis and Golfer's Elbow.

Lateral and medial epicondylitis are common in sports and work activities that require repetitive gripping or exert acute forces on the forearm. Left untreated, epicondylitis may interfere with daily activities. Most patients respond to early conservative treatment consisting of activity modification, ice, anti-inflammatory medications, and rehabilitation exercises. Approximately 5% of patients will fail conservative treatment and require surgery. The outcome for most patients following surgery is excellent.

Home Exercises for Tennis and Golfer's Elbow.

The essential exercises for a home rehabilitation program for tennis or golfer's elbow include stretching and strengthening (figure 1) to improve flexibility and range of motion, and to reduce forces on the affected tendon. Slow, passive stretching exercises and gentle strengthening exercises can be started right away.