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Type of tissue that connects muscle to bone

A tendon or sinew is a tough band of dense fibrous connective tissue that connects muscle to bone. It sends the mechanical forces of muscle contraction to the skeletal system, while withstanding tension. Tendons, like ligaments, are made of collagen. The difference is that ligaments connect bone to bone, while tendons connect muscle to bone. There are about 4000 tendons in the adult human body

A tendon is made of dense regular connective tissue, whose main cellular components are special fibroblasts called tendon cells (tenocytes). Tendon cells synthesize the tendon's extracellular matrix, which abounds with densely packed collagen fibers. The collagen fibers run parallel to each other and are grouped into fascicles. Each fascicle is bound by an endotendineum, which is a delicate loose connective tissue containing thin collagen fibrils and elastic fibers. A set of fascicles is bound by an epitenon, which is a sheath of dense irregular connective tissue. The whole tendon is enclosed by a fascia. The space between the fascia and the tendon tissue is filled with the paratenon, a fatty areolar tissue. Normal healthy tendons are anchored to bone by Sharpey's fibres.

Collagen fibres coalesce into macroaggregates. After secretion from the cell, cleaved by procollagen N and C proteases, the tropocollagen molecules spontaneously assemble into insoluble fibrils. A collagen molecule is about 300 nm long and 1–2 nm wide, and the diameter of the fibrils that are formed can range from 50–500 nm. In tendons, the fibrils then assemble further to form fascicles, which are about 10 mm in length with a diameter of 50–300 μm, and finally into a tendon fibre with a diameter of 100–500 μm. The collagen in tendons are held together with proteoglycan (a compound consisting of a protein bonded to glycosaminoglycan groups, present especially in connective tissue) components including decorin and, in compressed regions of tendon, aggrecan, which are capable of binding to the collagen fibrils at specific locations. The proteoglycans are interwoven with the collagen fibrils their glycosaminoglycan (GAG) side chains have multiple interactions with the surface of the fibrils showing that the proteoglycans are important structurally in the interconnection of the fibrils. The major GAG components of the tendon are dermatan sulfate and chondroitin sulfate, which associate with collagen and are involved in the fibril assembly process during tendon development. Dermatan sulfate is thought to be responsible for forming associations between fibrils, while chondroitin sulfate is thought to be more involved with occupying volume between the fibrils to keep them separated and help withstand deformation. The dermatan sulfate side chains of decorin aggregate in solution, and this behavior can assist with the assembly of the collagen fibrils. When decorin molecules are bound to a collagen fibril, their dermatan sulfate chains may extend and associate with other dermatan sulfate chains on decorin that is bound to separate fibrils, therefore creating interfibrillar bridges and eventually causing parallel alignment of the fibrils.

The tenocytes produce the collagen molecules, which aggregate end to end and side to side to produce collagen fibrils. Fibril bundles are organized to form fibres with the elongated tenocytes closely packed between them. There is a three dimensional network of cell processes associated with collagen in the tendon. The cells communicate with each other through gap junctions, and this signalling gives them the ability to detect and respond to mechanical loading. These communications happen by two proteins essentially: connexin 43, present where the cells processes meet and in cell bodies connexin 32, present only where the processes meet. Blood vessels may be visualized within the endotendon running parallel to collagen fibres, with occasional branching transverse anastomoses. The internal tendon bulk is thought to contain no nerve fibres, but the epitenon and paratenon contain nerve endings, while Golgi tendon organs are present at the myotendinous junction between tendon and muscle. Tendon length varies in all major groups and from person to person. Tendon length is, in practice, the deciding factor regarding actual and potential muscle size. For example, all other relevant biological factors being equal, a man with a shorter tendons and a longer biceps muscle will have greater potential for muscle mass than a man with a longer tendon and a shorter muscle. Successful bodybuilders will generally have shorter tendons. Conversely, in sports requiring athletes to excel in actions such as running or jumping, it is beneficial to have longer than average Achilles tendon and a shorter calf muscle. Tendon length is determined by genetic predisposition, and has not been shown to either increase or decrease in response to environment, unlike muscles, which can be shortened by trauma, use imbalances and a lack of recovery and stretching. In addition tendons allow muscles to be at an optimal distance from the site where they actively engage in movement, passing through regions where space is premium, like the carpal tunnel. Energy storing tendons can store and recover energy at high efficiency. For example, during a human stride, the Achilles tendon stretches as the ankle joint dorsiflexes. During the last portion of the stride, as the foot plantar flexes (pointing the toes down), the stored elastic energy is released. Furthermore, because the tendon stretches, the muscle is able to function with less or even no change in length, allowing the muscle to generate more force. The mechanical properties of the tendon are dependent on the collagen fiber diameter and orientation. The collagen fibrils are parallel to each other and closely packed, but show a wave like appearance due to planar undulations, or crimps, on a scale of several micrometers. In tendons, the collagen fibres have some flexibility due to the absence of hydroxyproline and proline residues at specific locations in the amino acid sequence, which allows the formation of other conformations such as bends or internal loops in the triple helix and results in the development of crimps. The crimps in the collagen fibrils allow the tendons to have some flexibility as well as a low compressive stiffness. In addition, because the tendon is a multi stranded structure made up of many partially independent fibrils and fascicles, it does not behave as a single rod, and this property also contributes to its flexibility. The proteoglycan components of tendons also are important to the mechanical properties. While the collagen fibrils allow tendons to resist tensile stress, the proteoglycans allow them to resist compressive stress. These molecules are very hydrophilic, meaning that they can absorb a large amount of water and therefore have a high swelling ratio. Since they are noncovalently bound to the fibrils, they may reversibly associate and disassociate so that the bridges between fibrils can be broken and reformed. This process may be involved in allowing the fibril to elongate and decrease in diameter under tension. However, the proteoglycans may also have a role in the tensile properties of tendon. The structure of tendon is effectively a fibre composite material, built as a series of hierarchical levels. At each level of the hierarchy, the collagen units are bound together by either collagen crosslinks, or the proteoglycans, to create a structure highly resistant to tensile load. The elongation and the strain of the collagen fibrils alone have been shown to be much lower than the total elongation and strain of the entire tendon under the same amount of stress, demonstrating that the proteoglycan rich matrix must also undergo deformation, and stiffening of the matrix occurs at high strain rates. This deformation of the non collagenous matrix occurs at all levels of the tendon hierarchy, and by modulating the organisation and structure of this matrix, the different mechanical properties required by different tendons can be achieved. Energy storing tendons have been shown to utilise significant amounts of sliding between fascicles to enable the high strain characteristics they require, whilst positional tendons rely more heavily on sliding between collagen fibres and fibrils. However, recent data suggests that energy storing tendons may also contain fascicles which are twisted, or helical, in nature an arrangement that would be highly beneficial for providing the spring like behaviour required in these tendons.

Tendons are viscoelastic structures, which means they exhibit both elastic and viscous behaviour. When stretched, tendons exhibit typical "soft tissue" behavior. The force extension, or stress strain curve starts with a very low stiffness region, as the crimp structure straightens and the collagen fibres align suggesting negative Poisson's ratio in the fibres of the tendon. More recently, tests carried out in vivo (through MRI) and ex vivo (through mechanical testing of various cadaveric tendon tissue) have shown that healthy tendons are highly anisotropic and exhibit a negative Poisson's ratio (auxetic) in some planes when stretched up to 2% along their length, i. e. within their normal range of motion. After this 'toe' region, the structure becomes significantly stiffer, and has a linear stress strain curve until it begins to fail. The mechanical properties of tendons vary widely, as they are matched to the functional requirements of the tendon. The energy storing tendons tend to be more elastic, or less stiff, so they can more easily store energy, whilst the stiffer positional tendons tend to be a little more viscoelastic, and less elastic, so they can provide finer control of movement. A typical energy storing tendon will fail at around 12–15% strain, and a stress in the region of 100–150 MPa, although some tendons are notably more extensible than this, for example the superficial digital flexor in the horse, which stretches in excess of 20% when galloping. Positional tendons can fail at strains as low as 6–8%, but can have moduli in the region of 700–1000 MPa. Several studies have demonstrated that tendons respond to changes in mechanical loading with growth and remodeling processes, much like bones. In particular, a study showed that disuse of the Achilles tendon in rats resulted in a decrease in the average thickness of the collagen fiber bundles comprising the tendon. In humans, an experiment in which people were subjected to a simulated micro gravity environment found that tendon stiffness decreased significantly, even when subjects were required to perform restiveness exercises. These effects have implications in areas ranging from treatment of bedridden patients to the design of more effective exercises for astronauts.

It was believed that tendons could not undergo matrix turnover and that tenocytes were not capable of repair. However, it has since been shown that, throughout the lifetime of a person, tenocytes in the tendon actively synthesize matrix components as well as enzymes such as matrix metalloproteinases (MMPs) can degrade the matrix. After about six weeks, the remodeling stage begins. The first part of this stage is consolidation, which lasts from about six to ten weeks after the injury. During this time, the synthesis of collagen and GAGs is decreased, and the cellularity is also decreased as the tissue becomes more fibrous as a result of increased production of collagen I and the fibrils become aligned in the direction of mechanical stress. In response to repeated mechanical loading or injury, cytokines may be released by tenocytes and can induce the release of MMPs, causing degradation of the ECM and leading to recurring injury and chronic tendinopathies. VEGF is well known to promote angiogenesis and to induce endothelial cell proliferation and migration, and VEGF mRNA has been shown to be expressed at the site of tendon injuries along with collagen I mRNA. Bone morphogenetic proteins (BMPs) are a subgroup of TGF β superfamily that can induce bone and cartilage formation as well as tissue differentiation, and BMP 12 specifically has been shown to influence formation and differentiation of tendon tissue and to promote fibrogenesis.

In animal models, extensive studies have been conducted to investigate the effects of mechanical strain in the form of activity level on tendon injury and healing. While stretching can disrupt healing during the initial inflammatory phase, it has been shown that controlled movement of the tendons after about one week following an acute injury can help to promote the synthesis of collagen by the tenocytes, leading to increased tensile strength and diameter of the healed tendons and fewer adhesions than tendons that are immobilized. In chronic tendon injuries, mechanical loading has also been shown to stimulate fibroblast proliferation and collagen synthesis along with collagen realignment, all of which promote repair and remodeling. and ornithischian dinosaurs, portions of the tendon can become ossified. In this process, osteocytes infiltrate the tendon and lay down bone as they would in sesamoid bone such as the patella. In birds, tendon ossification primarily occurs in the hindlimb, while in ornithischian dinosaurs, ossified axial muscle tendons form a latticework along the neural and haemal spines on the tail, presumably for support.