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Review
. 2021 Aug 11;9(8):23259671211020731.
doi: 10.1177/23259671211020731. eCollection 2021 Aug.

Injuries in Muscle-Tendon-Bone Units: A Systematic Review Considering the Role of Passive Tissue Fatigue

Maria C P Vila Pouca  1   2 , Marco P L Parente  1   2 , Renato M Natal Jorge  1   2 , James A Ashton-Miller  3
Affiliations
Review

Injuries in Muscle-Tendon-Bone Units: A Systematic Review Considering the Role of Passive Tissue Fatigue

Maria C P Vila Pouca et al. Orthop J Sports Med. .

Abstract

Background: Low-cycle fatigue damage accumulating to the point of structural failure has been recently reported at the origin of the human anterior cruciate ligament under strenuous repetitive loading. If this can occur in a ligament, low-cycle fatigue damage may also occur in the connective tissue of muscle-tendon units. To this end, we reviewed what is known about how, when, and where injuries of muscle-tendon units occur throughout the body.

Purpose: To systematically review injuries in the muscle-tendon-bone complex; assess the site of injury (muscle belly, musculotendinous junction [MTJ], tendon/aponeurosis, tendon/aponeurosis-bone junction, and tendon/aponeurosis avulsion), incidence, muscles and tendons involved, mechanism of injury, and main symptoms; and consider the hypothesis that injury may often be consistent with the accumulation of multiscale material fatigue damage during repetitive submaximal loading regimens.

Methods: PubMed, Web of Science, Scopus, and ProQuest were searched on July 24, 2019. Quality assessment was undertaken using ARRIVE, STROBE, and CARE (Animal Research: Reporting In Vivo Experiments, Strengthening the Reporting of Observational Studies in Epidemiology, and the Case Report Statement and Checklist, respectively).

Results: Overall, 131 studies met the inclusion criteria, including 799 specimens and 2,823 patients who sustained 3,246 injuries. Laboratory studies showed a preponderance of failures at the MTJ, a viscoelastic behavior of muscle-tendon units, and damage accumulation at the MTJ with repetitive loading. Observational studies showed that 35% of injuries occurred in the tendon midsubstance; 28%, at the MTJ; 18%, at the tendon-bone junction; 13%, within the muscle belly and that 6% were tendon avulsions including a bone fragment. The biceps femoris was the most injured muscle (25%), followed by the supraspinatus (12%) and the Achilles tendon (9%). The most common symptoms were hematoma and/or swelling, tenderness, edema and muscle/tendon retraction. The onset of injury was consistent with tissue fatigue at all injury sites except for tendon avulsions, where 63% of the injuries were caused by an evident trauma.

Conclusion: Excluding traumatic tendon avulsions, most injuries were consistent with the hypothesis that material fatigue damage accumulated during repetitive submaximal loading regimens. If supported by data from better imaging modalities, this has implications for improving injury detection, prevention, and training regimens.

Keywords: fatigue damage; muscle injuries; muscle-tendon-bone injuries; systematic review.

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Conflict of interest statement

One or more of the authors declared the following potential conflict of interest or source of funding: Research reported in this publication was supported by US Public Health Service awards P30 AG024824, P30AR069620, and R01 AR054821. The authors also acknowledge support from the Portuguese Foundation for Science and Technology under grant SFRH/BD/136213/2018 and funding provided by the Associated Laboratory for Energy, Transports and Aeronautics (Portugal) under project UIDB/50022/2020. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
PRISMA flowchart detailing study identification and record-screening process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Figure 2.
Figure 2.
Injury site distribution among the patient cohort (n = 3,246). AV, tendon avulsion; M, muscle belly; MTJ, musculotendinous junction; T, tendon; TB, tendon-bone junction.
Figure 3.
Figure 3.
Box-and-whisker plot (median, 25th percentile; range, 75th percentile) of patient age by injury site (n = 2,106). *P < .001. One-way analysis of variance. Dots appearing outside the whisker are outliers (observations numerically distant from the rest of data). AV, tendon avulsion; M, muscle belly; MTJ, musculotendinous junction; T, tendon; TB, tendon-bone junction.
Figure 4.
Figure 4.
Distribution of proximal and distal locations within each muscle by injury site (n = 2,328). AV, tendon avulsion; MTJ, musculotendinous junction; T, tendon; TB, tendon-bone junction.
Figure 5.
Figure 5.
Comparison of onset of injury category by injury sites (n = 1,772). AV, tendon avulsion; M, muscle belly; MTJ, musculotendinous junction; T, tendon; TB, tendon-bone junction.
Figure 6.
Figure 6.
Injury distribution by muscle/tendon and injury site (n = 2,832) and mean ± SEM age by muscle/tendon (n = 2,106). Patient age was not reported for ADL, TMIN, and QF injuries. ACT, Achilles tendon; ADL, adductor longus; AV, tendon avulsion; BB, biceps brachii; BCH, brachialis; BF, biceps femoris; DLT, deltoid; ED, extensor digitorum; EDM, extensor digiti minimi; EHL, extensor hallucis longus; EIP, extensor indicis proprius; EPL, extensor pollicis longus; FPL, flexor pollicis longus; FPT, flexor profundus tendon; GMED, gluteus medius; GMIN, gluteus minimus; GRC, gracilis; GST, gastrocnemius; IAB, internal abdominal; IP, infraspinatus; LD, latissimus dorsi; M, muscle belly; MTJ, musculotendinous junction; PAT, patellar tendon; PB, peroneus brevis; PL, peroneus longus; PM, pectoralis major; POP, popliteus; QF, quadratus femoris; QT, quadriceps tendon; RF, rectus femoris; SC, subscapularis; SM, semimembranosus; SP, supraspinatus; ST, semitendinosus; T, tendon; TB, tendon-bone junction; TBL, tibialis posterior; TFL, tensor fasciae latae; TMIN, teres minor; TMJ, teres major; TR, triceps brachii; VI, vastus intermedius; VL, vastus lateralis; VM, vastus medialis.
Figure 7.
Figure 7.
Distribution of injuries by musculotendinous group and proximal and distal locations (n = 2,328). ACT, Achilles tendon; BB, biceps brachii; BCH, brachialis; BF, biceps femoris; DLT, deltoid; ED, extensor digitorum; EDM, extensor digiti minimi; EHL, extensor hallucis longus; EIP, extensor indicis proprius; EPL, extensor pollicis longus; FPL, flexor pollicis longus; FPT, flexor profundus tendon; GMED, gluteus medius; GMIN, gluteus minimus; GRC, gracilis; GST, gastrocnemius; IAB, internal abdominal; IP, infraspinatus; LD, latissimus dorsi; PAT, patellar tendon; PB, peroneus brevis; PM, pectoralis major; POP, popliteus; QF, quadratus femoris; QT, quadriceps tendon; RF, rectus femoris; SC, subscapularis; SM, semimembranosus; SP, supraspinatus; ST, semitendinosus; TBL, tibialis posterior; TFL, tensor fasciae latae; TMIN, teres minor; TMJ, teres major; TR, triceps brachii; VI, vastus intermedius; VM, vastus medialis.
Figure 8.
Figure 8.
Comparison of onset of injury category (in percentages) by injured muscle/tendon (n = 1,415). ACT, Achilles tendon; BB, biceps brachii; BCH, brachialis; BF, biceps femoris; ED, extensor digitorum; EDM, extensor digiti minimi; EHL, extensor hallucis longus; EIP, extensor indicis proprius; EPL, extensor pollicis longus; FPL, flexor pollicis longus; FPT, flexor profundus tendon; GRC, gracilis; GST, gastrocnemius; IAB, internal abdominal; IP, infraspinatus; LD, latissimus dorsi; PAT, patellar tendon; PB, peroneus brevis; PL, peroneus longus; PM, pectoralis major; POP, popliteus; QF, quadratus femoris; QT, quadriceps tendon; RF, rectus femoris; SC, subscapularis; SM, semimembranosus; SP, supraspinatus; ST, semitendinosus; TBL, tibialis posterior; TFL, tensor fasciae latae; TMJ, teres major; TR, triceps brachii; VI, vastus intermedius; VL, vastus lateralis; VM, vastus medialis.
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References

    1. Äärimaa V, Rantanen J, Heikkilä J, Helttula I, Orava S. Rupture of the pectoralis major muscle. Am J Sports Med. 2004;32(5):1256–1262. - PubMed
    1. Abramowitch S, Easley D. Introduction to classical mechanics. In: Hoyte L, Damaser M, eds. Biomechanics of the Female Pelvic Floor. Academic Press; 2016:89–107.
    1. Andersen E. Triceps tendon avulsion. Injury. 1986;17(4):279–280. - PubMed
    1. Anzel SH, Covey KW, Weiner AD, Lipscomb PR. Disruption of muscles and tendons: an analysis of 1,014 cases. Surgery. 1959;45(3):406–414. - PubMed
    1. Asinger DA, el-Khoury GY. Tensor fascia lata muscle tear: evaluation by MRI. Iowa Orthop J. 1998;18:146–149. - PMC - PubMed

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