MepioNe AND SciNCE SPORTS Wo TN, 8p 185175 1978 The influence of physical activity on ligaments and tendons ABSTRACT. Using either hone-lgmentbone or a muscle {endon-bone prepsatin, numerous Investigators fave dam Stated thatthe usal te of sepantion fan the transitional zone between the ligament (or fendeo) and bone; hene, the {orm junction strength or lod at separation is wed to describe functional changesin these preparations, junction stongth de. ceased with inatvily (mobilization) and tereabed with hronieatvity (taining provided thatthe exerts progean & ff an endurance nature ‘Training also increases jetion Strength in thyroldestamized and hypophysectomtzed Fats Be Side changes In Jonetion strength, traning rels In heaser ligamonte and higher igomoot swaght/lngth rates. However, water content, collagen concentrations /dry weight or collagen concentration por weight/logth unit aro not sighieanty In fluenced by repeated bouts of exercie. Although immobiia is ssciatd with lower elastic stifnese values (xg/mm) {caning appears tohave ite nunc on this messare in nor ‘nal animal Rats and dogs with surglally repaired ligaments fre weaker and thestrength renls ae markedly lower if tho leg ieimmobiized Exc taining improves th repairstrength of Higaments but does ot result normal vals twelve weeks al ter the surgery. Exogenous adminitration of ICSHT or test Gsterone results i higher fepair stength wheress. TSH, Uiyrarne, ACT and growth hermene decreas ths mesure W was concloded that the mechunid! ses prodicel by yonte exerts isan important determination ofthe strength of epared ligaments andof the junetionshetwoon ligaments (or tendons) and bones CONNECTIVE TISSUE, EXERCISE, LIGAMENTS, TENDON, BONE, Despite the fact that connective.tissue is abundantly Aistributed throughout the body, few physiologists have exhibited a serious interest in its functional capabilities. A brief summary of the anatomical and histological charac- teristics of this tissue is included in Table 1. Since nurner- us cell and tissue types are encompassed within the dassiication of connective tissue; only experimental find- ig related to ligaments and tendons will be emphasized in this review. These tissues consist of fibroblasts, fbro- cytes, ground substance, and fibers, The fibers ate pre- dominantly collagenous although some elastic and reticular types are present in certain ligaments. Although many of the details need to be elucidated, it is generally accepted that fibroblasts are responsible for the forma- tion of collagen. It has been estimated that 1,500 papers a year are published on the subject of collagen (62); there- Sie fr pean Apt, 1. ep or plenon uy 975 CHARLES M. TIPTON, RONALD D. MATTHES, JERRY A. MAYNARD, AND RITA A, CAREY Exercise Physiology Laboratory University of Iowa Towa City, Iowa 52242 fore, this review will pertain to only those aspects which relate to the effect of exercise. For more details on colla- gen, the following references (10, 12, 15, 17-20, 24, 34, 36, 37, 65-68) should be consulted. Ligaments or tendons function in a complex that in- volves either bone-ligament-bone or a bone-tendon- muscle-tendon-bone unit (67). As most of our data has evolved from studies involving the fermur-medial colla- teral ligament-tibia preparation, specific changes involy- ing this ligament or preparation will be emphasized. Ligament or Tendon-Bone Complexes * Ina bone-ligament-bone or a bone-tendon-muscle-ten- don-bone preparation, it is extremely difficult to secure the precise area and length measurements necessary for TABLE 1 Simgttegantonical and histbgea vei A PRIMARY TSSUE TYPES 1 Epithet 2 Goenetve 4, Musab 4 Nenexs 8 CLASSIFICION OF CONNECTIVE TISSUE 1. Loose Oinary 2 Dense Orinry 4. Hemopitic CELL TYME 1, loose Orinany Conectie Tsue 4. Fiboblets bat © Plasma 1 Macophages Maat 1, Unditeentts Mesenchymal 2 Dense Ordinary Connective Tissue 4 Fiboblas 1, Chondcblas € Ostablats ©, BER TYRES FOUND I LIGAMENTS, TENDONS AND BONES 1 Calageous 2. Baste 4. fate Hod from A.W. Har’ txt of Wit, 6h Edn, J.B. Lipptot Co, Phi eli, 196, pp 169-187, 205257, 376455.166 bo Seperation (ko) Figure —Loud-elangation relationship fy an in sity bonetigament- bone medial collateral preparation. ‘The spindle i connected to the ma- of the i he load at separation junction strength, A schematie diagram ofthe prep- reference 83, The linetr portion ofthe tracing is Wako refered to tration ean be seen measure of the elastase of the Higament (kg/m) whereas the tren unier the loxl-longation record & the failure energy and ex preved in gram-em wants the calculation of stress (Force/area) and strain (length/ initial length) units. We have found, as have others, that in bone-ligament-bone preparations, the separation oc- ‘aus at the insertion site (13,60,70). Similar results have been obtained with tendons although failures have also ‘oceurted at the musculo-tendinous junction or within the muscle (67). Over the years, a variety of methods have evolved! to measure the strength of intact ligaments or tendons in isolated preparations (1,19,52,53,55,56, 60,61,63,66,70). Recently, we have perfected an in situ technique (55) for rats which is a modification of the in vitro method we used to test bone-ligament-bone prepe- rations from rats and dogs (52,53). Figure 1 is a tracing of, an in situ record obtained from an anesthetized rat, Al- though a variety of terms have been employed to define a strength change (eparation force, failure load, tensile load, breaking point)) we prefer to use the terms junction, strengih or load at separation. When we compared our recent results obtained from in situ preparations with our earlier results secured from isolated preparations, small but statistically significant dif- ferences existed (55). Therefore, we repeated many of our experiments using the in situ preparation and the findings confirmed our conclusions obtained from the isolated preparations (6,7,51-54,58,59). Elliott and Crawford (15) as well as Viidik (61) have ef- fectively used a weight/length index to approximate ceross sectional areas of small tendons. We examined this relationship in rat ligaments (Figure 2) and found the same significant relationship existed although the correla tion coefficient of .554 was markedly lower than the ones reported for tendons. This is understandable as it is x= MEDICINE AND SCIENCE IN SPORTS $= 043% oWW/Lt 0.1229 sp q=2 0692 12.984 nens EO 120 180 240 300 360 Ae 480 540 G00 LIGAMENT WET WEIGHT/LENGTH (mg/mm) 1e 2-The relationship between cross sections area and the medial collateral ligament wet weight/leagth unit of ras, Tn larger structures ‘Such a tendons, a higher statisti eelationship has been obtained, © | El fF 2 a | 2 mt = oe : iti) ie L i : al mt “| fe - ie | Figure 3~Janetion strength measirenents of different knee lignmen tre animals per group. Meems. aia published in The Journal of Bone and Joint Surgery, 9A, 1987. tremely difficult to secure previse thickness _measure- ‘ments on rat ligaments. Junction strength must be interpreted with regard to the ligament being tested (Figure 3), differences in age (8), sex (8.52), body weight (8,52,56), endocrine statis (61,55,57,59), and the physical activity level of the ani als (1,5,32,51-56,59,60,62,63,70-71). To reduce the vari- ability between groups, junction strength is expressed on a body weight basis. As can be observed in Figure 4, the junction strength/body weight ratio is fairly constant over a wide range of body weights in rats, In dogs (63) the same relationship exists between these two par meters (Table 2). Im male and female rats, janetion strength and lige ment weight are highly correlated (> 90) until the ani- mals are 135 days old (unpublished data). As the animals become older this relationship decreases and the correli-EXERCISE AND CONNECTIVE TISSUE tion coefficients becomes lower (Figure 5). While it ‘would be convenient to assume that all ligament and ten- don junctions adapt similarly to various experimental con itions, this is an oversimplification and should be avoided, For example, immobilization has more of an ef- fect on the tibial insertion site than upon the femoral sertion site (32). Of the ligament junctions tested (Figure 3), the medial collateral junction was the weakest and this fact may partially explain its high injury incidence in athletic events (322,48). The Influence of Physical Activity on Junction Strength Before one can attribute an adaptive response to re- peated periods of exercise (training), it must be demo: strated that the changes are not the result of a single bout. Therefore, the effects of 30-minutes of running on the junction strength and on the weight of the medial col- lateral ligament of nontrained rats was measured. After a single bout of exercise there were no statistically signi cant differences between runners and non-runners of simi: lar body weights (Table 3), To determine whether a decrease in physical activity level alters junction strength, tenectomy of the Achilles tendon was per- formed on rats. Although lower group means were ob- served (56), the changes were not statistically significant. Therefore, the hind legs of rats (Table'3) and dogs (Figure 6) were immobilized in plaster casts for six weeks or 167 4 | Figure 4—Junetion stegth ody weight ratio af male rats of various weights. Means and SE Tsted. Modified from data published in The Toumel of Bone and Joint Surgery, A9A:68, 1967 higher than in the casted legs. However, with immobiliza- tion, the noncasted legs became stronger because of in- creased weight bearing; therefore, junction strength evaluations were made using regression equations (Figure 5) developed from normal animals (55). The results were longer. In both groups, the strength of the medial colla- the same; namely, junction strength was lower in immobi- teral ligament-tibial junction of the noncasted legs was lized legs. WAKE 2, Sisal lancis between steed grant _ 4 CONPARSON BETWERN RT AND LEFT LEGS OF HALE RATS (2. SE. - Caetatin Col fet Between Panels 8 ahi tes leftLer igh 2 Loft ers 1, Weta a) Ma 420 0 4.73 98 198° 2 rywett (ne) 50 Le #82 INS 2 032 ‘aor 1 Water peconage 0 6 = 6330 2 087 ise 4 iganet Lenth na) 138 gai + 9 318 + 09 86° 5. Wetweiht/inain 139 0.Mg = 011 0458 = 010 6 © Dryweahtcath 0 O07 05 Ou. 04 42k 8. CORRELATION OOEFICIENTS BETWEEN BODY WEIGHT, AND SELECTED PARAMETERS. " ' 1 Wet weit eiganes fen sut ats M5 a8 2. Ory olizane fem aut is 4 3" 3. lunconstreith at) 18 slo 4 lunion teeth (das) 59s 6. CORRELATION COEFRCIENIS BETWEEN JUNCTION STRENGTH AND SELECTED PARAMETERS FROM ADULT MALE RATS, 1, Wet weit ligaments “ 057 2 Ory weit oliganens 0 005, 5. Wetweihtengts “ 245 4 Ory night length 0 318° . “ates 8 cretion coc tat was stay siifican t e168 In exercise studies itis important to demonstrate that the exercise program being used is capable of producing significant anatomical and physiological changes. It has been shown in previous investigations that our 10-week endurance training schedule results in significant changes in heart weight, organ weight, heart rate, serum choles- terol, adipocyte diameter and enzyme detivity (6,7,35, 50,51,58). Since body weight is usually lower in trained animals, experiments were conducted in which the body ‘weights of the nontrained animals were maintained at the same weights of the trained animals, This was accom- Foseescaoorx Figure 5~Staistial relationship between body weight and insitu june: tion strength of adult male rats, For Female rats (N'=28) the eorcelation ‘ocfleent was .674 (55). Separation foree was esleulaed using a con ‘stant of 880251.701 gals (5) MEDICINE AND SCIENCE IN SPOTS plished by monitoring and regulating their daily food con- sumption. In these experiments, the trained animals had significantly heavier ligaments, higher junction strength and junction strength/body weight ratios (Figure 7, Table 3). The same trend occurred with studies on dogs (Figure 6). Similar experimental results from rut and rab- Dit ligaments have been reported by Adams (1), Viidik - | : to i” i " ig eer h (fal ie i 3 TE Tel {Elle A bol lh | i i ELLE wl tea] FNAL TEL] ET TE a i BULLE a Figure 6—Junction strength/bady weight ratios of male mongrel dog. assigned to different activity groups. Means, SE lted, the body ‘weights (kg are in parenthesis and ne group has less than 4 dogs white ‘mast had 10 or more. The dimensions of the cages were 31” x31” x31" ‘whereas the open pens were 6” 15'. The minimal experimental peed ‘was 6 weeks, Further detals ean be located in J. Bone Joist Surg, 534 275286, 1071. TABLE 3, nln of physi actity om stengh and elongation characteris of ment one jrtins of as. Final Body Separation ——_Juncn Fale Este Total longa at Weht Force strenglny Enurg Sites Eangtion tad of LSDkg Group NK Groms) Wewton) Body eight Gramem) (g/m). (um) (om) losILZeD CONTROL Cont! 1 32H 12 HS LAM GMS + OGY DS TOD 1.009 HS 2a Casted 9 MSE 12 183195 SOM aeB 75104 330882 & NT aM Re SINGLE BOUT OF EXEROSE Nonruners 10 M64 7 BADE OMD S77 2284504156 OBBL 4 BL anes funners 10 MS 7 18S 108 SASS 3D 26504 197 OBR 4 ON 2a s 9 SPRINT EXEROSE TRAINED Nontained 16 AQ 4IS 735A 1OE GOS EID THT IRS LAE IL 38272 EL Tred Mo M712 827 OBE §OBG 786 FSA T34 LOE BSH E20 2B ENDURANCE EXEROSE TRAINED NORUAL GROUP Nentained 37 Me 6 ANOBII AS HISD LIE e ANS 2H ET Trained 37 0 6 © HAT EOBEY G01 4 05" SOLO 253" LIB 63S OYE ENOURANCE EXEROSE TRAINED THYROIDECTOMIZED Nntained 1 37415 QE LAT SQ DD HIM OMA WE «BH OZ EL Trained HM 37410 BIS LAT 7021 EAS" HSA 190 O81 MA. BER — 2A ES ENDURANCE EXEROISE TRAINED HYPOPHYSECTOMIZED Nonteined 2 te THEONION 08H A 205 Tained gies 2 1744038910 e256 19 O08 WO? 3H 039 The mci cose Hgamentibial uncon was teste. Moans and SE ied, * denotes ypenystlonaed dss were obtained ram relerence (55), grup diferece that was statisicaly sgn t 6 lvl, Te thridEXERCISE AND CONNECTIVE TISSUE J st it be 4 tL i g i i i a 8 Figure 7-Iullnce of endurance exercise tnéning om the junction feng of the mela caters Yigamentailprepuation fn male Sprague Davey rat Tho oper rtuts wer fom stale in wich the temvrunners were permitted fo conume foo nan ad Tita manner Camequenty they were savior hn the runner. Each grovp had $5 Shimek, The lover rests were ebtained fron runner andre fer of sine body weighs In theo ivestgaions the now ranners SG dhe ford intake rite yo thst both ous ened weight at tocamo mis The were ae at pergtup rbot des the Scngth/body weigh ios were sigently higher inthe trained oun. (6063-64), and Zuckerman and Stull (70,71). ‘AS connee- tive tissue is very responsive to repeated mechanical in- fences (15,19,30,60, a study was undertaken to determine the effects of sprint b “This exercise schedlle consisted of frequent sprints of 2 two-minute duration up a 20% grade with rest periods of 05 min. The total time was progressively increased until the rats were exercising for two-hrs/day. The results, sum- marized in Table 3, clearly showed no improvement in junction strength of the sprint trained group even though the weight and the weight/length ratio were markedly in- creased (Table 4). This finding is important because it demonstrates that ligament weight and junction strength do not exhibit concomitant changes in response to this type of exercise-training, These results not only reinforce the “specificity of exereise” concept, they also suggest that changes in junction strength are dependent on the Figure 8-Influence of immobilization andor endurance exerebe train: ing on the junetion strength of male hypophysectumized rats. Values fare means and SE. The number of animals in each group is given in parenthesis, type of exercise performed and not solely on the time de- Voted to exercising. Itis well documented that connective tissue is very re- sponsive to hormonal influence (2,4,11,1425,28,29, 31,33,68). Furthermore, itis equally well known that the plasma levels of numerous hormones are altered by exer- cise (21,39,40,42,47,18,59). To determine if the increase {in junction strength induced by exercise training is de- pendent upon levels of certain hormones, experiments on the effects of exercise were conducted on rats with vari- fous endocrine deficiencies. Like normal rats, endurance trained thyroidectomized and hypophysectomized rats had significantly higher junction strength /body weight ra- tios than their nonexercised controls (Table 5, Figure 8) ‘When hypophysectomized rats were immobilized, they had significantly lower junction strength measures than their controls. In experiments conducted on male hy- pophysectomized rats that were exercised while receiv- ing daily injections of either TSH, ICSH, or testosterone, junction stiength was significantly increased in each group (58); in contrast, ACTH and GH injections ap- peared to have little effect. Adrenalectomized rats were also chronically exercised (57) and the trained group was associated with lower rather than higher junction strength values. We have not been able to demonstrate a training effect on junction strength in normal female rats (754) or in trained ovariectomized females receiving es- trogens (7). These findings, which are in confict with those of Adams (1), were unexpected and additional re- search is needed to resolve this matter, There have been few studies in which tensile strength ‘was measured in isolated tissue preparations from exer-, cised trained animals Viidik exercised male rabbits for 40 weeks and messured the tensile strength of four separate tendons at the time of sacrifice (62). Regardless of how the results were expressed, i.e, Newtons or in Newtons per length/weight unit, no statistically significant changes in strength were observed. Viidik concluded that170 TABLE 4 nunc of physical city onthe site and water contet of igaments roa rl MEDICINE AND SCIENCE IN SPONTS Wet Body Wel Dy Dy Weigit Langit eight Wepht = eipity With Theta Condon = NM Grans) (mm) (oo (0) 0 Length Legh (om) (0) SINGLE SOUT OF EXEROE Nomuers 10 36+ 7 86413 300.1 1257 £.065 SLE OT 3594.05 144.005 LA Me 105 2.005 tumers 10 36+ 7 87£19 2B + OM 125.083 S624 06 M94 O16 48+.005 144 ts 219 4.0% ‘SPRINT EXERCISE TRAINING Nonteind 16 AHI BISI9 U7 +.ID 1304073 SPOk OG? TEE OT 1595007 144. 7104.08 Trained 16 45 £10 B6E IT 3500S IS 1580 OSS S77 O69 MIB +017" 179-5 008" 154.06 1 +018 ENDURANCE EXERCISE TRAINING Nonraied. 37 A+ G§ LL ANZ OF 16H 4.005 GOL 090 M01 O10 159 2.008 Nat at Traiees 37 ae 6 WOT427 ANS 4 16 LBL 4.075" KOZ O7O M9 x O12 (173 =.005" Nesued Meares INacTY BY HH OBLATION Castd leg 9 3M 410 Rol 3.7 5 SEY L210 GTA L6H at at Not at Noncased leq 9300 10 Measured 3.08 + 161 1265 + 161 694+ 070 _Meswret _Measwed _Mesurad_ Messed Themedial steal lgpment ol te haee was measure, Meas and SE Ise, ® dena 2 mated group test TABLE 5. eduene of endurance rs tréning on at eames rom male thy la Wet Oy iter Crop Ni Wolk (ms) Meiht (oa) Percentage THRO DECroMIRED Nomad 15 4062.76 1584 086 61.6 = 080 Trlned 1 4459 BL 1703 O85 62.8 052 vvpopaysecrowzeD Nomad 12 3056-4111 LIN M34 639 092 __lweied__11._ 325641113 old 65.1 = 034 Mears and SE sed there wee no pup dfernces thal were stisialsiaif- ant at 05 lel. Table and Fur 7 contain ooo data om nomal als. Mesure rls real to lent, with and tines were et ote, these tendons had adapted to the functional demands of exercise without an increase in mass, Since no evidence of a training effect was presented, it is possible the train- ing program used was inadequate for this purpos It is extremely dificult to secure meaningful objective data on the strength of the bone-ligament-bone or muscle-tendon-bone complex of humans, For this reason, the term “knee stability” is preferred and used instead of junction strength, Kleiti developed an instrument that measures the ab- duction and adduction movements of the knee joint and used his data as an indirect method to assess the stability of the ligaments of the knee (27). In his early studies, he concluded that deep knee bends with weights were in- jurious to the ligaments of the knees and could increase the “injury potential” of that individual. As a result of these findings and the earlier statements of the AMA ‘Committee on the Medical Aspects of Sports’, deep knee bends were discouraged in many educational and military institutions. Subsequent research by Karpovich et al (26), Sprague et al, (1966 Ph.D. thesis at the University of Iowa), and Moorehouse et al. (personal communication) rap diferece tat was satisicaly sight al.05 level usig eer x oneal 2 have not confirmed these results. Their findings indicate that (a) deep knee bends with weights will improve knee stability provided that the placement of the feet causes no lateral rotational effects upon the structures of the knee and that (b) there is very little predictive relation- ship between knee stability measurements and the inci dence of knee injuries during a football season, Morphological, Biochemical and Rheological Considerations Inthe previous section it was emphasized that the june- tion strength of bone-ligament-bone preparations was higher with increased activity and lower with decreased activity. These results necessitate a closer examination of the insertion site. Interest in this subject is not new as the topic has heen under discussion since 1691 (12). With the advent of the electron microeope and the scanning elec- tion microscope it is possible to describe in great detail the nature of the insertions of ligaments and/or tendons into bone. Cooper and Misol (12) and Laros et al. (32) have shown that the insertions of ligaments and tendons involve a transition from ligament to non-mineralized fibrocartilage to mineralized fbrocartilage to bone, As- pects of this relationship can be seen in Figure 9. There- fore, any condition that alters one or more of these zones can influence the junction strength of ligament or tendon preparations. We have observed in immobilized dogs a widespread subperiosteal bone resorption that is replaced by fibrous tissue which ultimately becomes mineralized (2), Electron microscopic examinations of boneliga- ment-bone preparations from normal rats suggest that the region of separation is between the zones of mineralized fbrocartilage and bone (unpublished observation). The reason for the separation being located at this site is un- clear. Equally uncertain is whether exercise training causes changes in the size and number of collagen fibrils[EXERCISE AND CONNECTIVE TISSUE Figure Electron microscopic representation of the insertion of the rat ine collateral ligament into the tibia L = ligament, ‘alized Abrocartilage and B= bone, The nowmincralized Abro- ‘arilage is located between the ligament and the mineralized zones, Magnifestion is 4850X, at the junction, increases in the amount or character of the ground substance and/or the mineral matrix, or in- creases the cohesive and adhesive forces around the fr brils, It is conceivable that changes within the bone near the junction are as important as the changes within the ligament in explaining the factors that modify junction strength. When the junction of a bone and ligament preparation 45 tested, a variety of measurements are obtained, Several are listed in Table 3. Since the endurance trained normal rats were stronger than nontrained rats, they-also had sig- nificantly higher failure energy values (area under the curve). A similar result was reported by Viidik (60) who used rabbits to study the effect of training on the strength of anterior cruciate ligaments, Rheological properties can be approximated from the measurements of elastic stff- ness (slope of the linear portion of the load-elongation curve), total elongation, and the elongation recorded at a specific load. Of the groups measured, only the immobi- lized animals exhibited changes which had statistical sig- nifieance (Table 3). Viidik has reported both higher and lower clastic stiffness values for tendons from trained groups (62) although we did not find the elastic stiffness of ligament preparations to be significantly altered by any group that was trained (Table 2). Like others, we have shown that elastic stiffness increases with age (55) and post mortem events (55), decreases with immobiliza- tion (Table 3), lathyrism (55), thyroidectomy" and hy- pophysectomy (Table 5). Tendons and ligaments have properties of viseq-el: city and plasticity (16,63,64,67) and it has been demon- strated that these properties will be modified by changes in the inter- and intra-molecular bonding of collagen, by the ratio of the soluble to the insoluble form of collagen im od Pen em BE my i } i Foal on ' z a Fah exo pel eco Figure 10—Influence of endurance exereise training onthe weight and the weight/length ratios of medial eallatraligaments from male rats. Upper results were from studies in whieh the now-runners were per mitted to eonsume food in an ad Iibitum manner. Consequently, they tvere heavier tan the runners. Each group had 58 animals per group. “The lower results were obtained from runners and wonrunners of sim lurbody weights There were 37 animalsin each group. With the exeep- tion ofthe water content, all differences were statistical $5 probability level. and by the water content, Viidik tested tendons from ‘rained and nontrained rats using thermal shrinkage procedures and found the tendons from nontrained ani: ‘mals (unpublished observation). The ligament results in ‘Tables 4-5 show that the water content was not altered by the endurance program even though the wet weights and the wet ligament weight/length ratios were signifi cantly higher in the normal exercised trained rats (Figure 10). These findings indicate that the ligaments had adapted to the stress of exercise by an increase in mass. It is uncertain whether this change is due to hyperplasia or to hypertrophy. However, there were no. significant changes in weight or weight/length ratios of ligaments from trained thyroidectomized or hypophysectomized rats (Table 5). Increases in the dry weight of ligaments suggest a change in their collagen content. Collagen is a fibrous protein that provides the nucleus for salt deposition in calcified tissues and the skeleton which holds “soft tis- sues” together to resist external mechanical forves, It is present in nearly all multicellular animals and constitutes * approximately 25% of the total protein within the body (18). While considered to be metabolically and mechani- cally inert, collagen does possess sufficient elasticity, vis cosity, plasticity and metabolic activity to warrant a ‘more refined description (65,67). On a dry wei172 collagen represents approximately 60-80% of the total ‘weight of tendons (15,19,45); thus, with any change in the wet or dry weights of ligaments or tendons, change in col- lagen concentration must be considered. Since hydrox- yproline is found almost exclusively in collagen, its ‘measurement in tissues has been used to detect or denote changes in collagen concentration. As less than 0.1% of the hydroxyproline incorporated into collagen is derived from dietary hydroxyproline (46), the hydroxylation of 'C-proline into "C-hydroxyproline is a wseful procedure to study collagen metabolism. Previously, we measured hydroxyproline levels in ligaments from dogs and found the trained group to have higher values (53). However, this difference has not been confirmed in rats. Hydro- xyproline results from 25 nontrained and 25 trained rats were (X, SE) 78 + 4 and 72 + 3 ug/mg dry ligament weight respectively. Viidik (62) also found no inerease in the concentration of collagen in tendons obtained from trained rabbits. . Booth and Tipton (8) demonstrated that a single exer- cise bout had no significant influence on the hydrohydrox- ylation of proline by isolated tendons. Inglemark (23) concluded that the cross sectional areas of the primary bundles of tendons secured from young mice were in- creased by training, Our ligament data (Table 4) supports this conclusion as ligaments from exercised trained nor- ‘mal animals tend to be heavier, wider and thicker. While these changes make it possible for trained animals to have more collagen/ligament (20), there is no difference between trained and nontrained animals when hydro- xyproline concentration is expressed on a weight/length basis (54). Heikkinen and Vuori recently studied the hy- droxyproline concentration in the Achilles tendons of mice and reported that training had increased the turn- over rates of collagen (20). ‘A decrease in activity (immobilization) is associated with a decrease in the width of the fiber bundles of knee tigaments from dogs (53) or from hypophysectomized rats (69). However, there was no statistical evidence that the collagen or hexosamine concentration of the dog liga- ments had been altered by six weeks of immobilization (53). Influence of Exercise on Repaired Ligaments Despite the fact that Hippocrates more than 2400 ‘years ago advocated exercise as being an important factor in the healing of injured ligaments (13}, there isa pau of scientific evidence to support this belief. Thisis surpri ing because there is a voluminous literature relating to the subjects of surgical repair and wound healing (13,17,25,29,33,36,49). To obtain information on this sub- ject, the medial collateral ligament of dogs was surgically transected. In these experiments, most dogs had their legs immobilized in plaster casts and were returned to their ‘cages where they remained for various time periods. MEDICINE AND SCIENCE IN SPORTS “ hewn Zeon Figure L1lafence of inmebization on sul ses meta tolitea limon of ale dogs: Meats andl Sar hed. The nam Sera animes por grou in perenne gs had paid Tigaments but wot meiied bad sigoanty higher stent vals (6) inn cepted gamers ible les When tested, the ligament will separate at its repair site; thus, we were able to use a boneligament-bone prepara- tion to determine the strength of a repaired ligament. With such a testing arrangement t is impossible to secure accurate messurements on ligament length and weight. ‘The findings presented in Figure 11 indicate that immobi lization is deleterious to the physiological and biochen- fecal processes that determine the strength of repaired ligaments. Dogs with repaired ligaments that were not immobilized had stronger ligaments than the animels with repaired ligaments whose legs were placed in plas- ter casts. However, it should be noted that in these casted animals the strength of the repaired ligament was markedly lower than the junction strength obtained from the contralateral leg, While itis clear (Figure 12) that im- mobilization will impede and that exercise will enhance repair strength, it should be emphasized that after a total of 12 weoks (six weeks of immobilization and six weeks of exercise training), the repair strength had not reached the junction strength level expected for normal dogs. Unpul- lished results suggest that between 15-18 weeks is needed before a “normal” value is obtained. How nach of this time period could be reduced with chronic exercise & ‘unknown. Since repaired ligaments are very responsive to endo ccrine influence, we repeated selected aspects of the dog ‘experiments using hypophysectomized rats. Like nomnal rats, their ligaments will respond to increased or de- creased levels of activity; thus, with immobilization their repair strength was lower and with cage activity and exer cise, their repair strength was higher. To secure information on the effects of different hor ‘mones on repair strength, we injected a single hormone daily for six weeks into male hypophysectomized rats whose ligaments had been repaired (59). We recognizedEXERCISE AND CONNECTIVE TISSUE the fact that the replacement of a single exogenous hor- mone does not duplicate the normal hormonal status or balance within an animal. Using this approach we found that ICSH and testosterone replacement increased the re- pair strength whereas ACTH, STH, TSH and thyroxine injections “weakened” or had no effect on the repair strength (Figure 13}. The growth hormone results were unexpected; therefore, we repeated these studies severel times over a three year period. However, the findings were the same and we have concluded that growth hor- mone, if injected alone, does not increase the strength of repaired ligaments in chronic animals. Figure 12-Influence of exercise, immobilization and recovery time on the strength of surgically repaired ligaments, Means and SE listed, no _group had less than 9 animale group. There were no body weight differ. fencer between the goups. Reprinted with permision from Am. J Physiol, 318:808, 1970, 173 While we believe that the changes in repair strength af- ter hormonal injections are due primarily to changes in collagen and glycosaminoglycan synthesis or degradation rates, we have no biochemical data at this time to sup- port these beliefs. We do have histological evidence that repaired ligaments are associated with increased capillari- zation and it has been demonstrated that the fractional blood flow going to the medial collateral ligarnentsis less than 0.1% of the cardiac output (55). Therefore, itis pos sible that exercise training is augmenting the blood flow and the availability of hormones to repaired ligaments. According to Rothman and Slogoff (41), capillarization is diminished by immobilization. Since itis well known that exercised trained animal populations have increased muscle and cardiae capillarization, physical activity may be improving the repair strength of ligaments through this mechanism. CONCLUSIONS 1. The junction strength of bone-ligament-bone prepa- rations is increased with exercise training and decreased with immobilization. This effect is best demonstrated in ‘male animals. 2 Junction strength is influenced by the presence of certain hormones; however, in hypophysectomized rats, junction strength is increased by exercise training and de- creased by immobilization. 3. The transitional zone between mineralized fibro- cartilage and bone is the site of most separations between ligaments and bones. This region appears to be the 9600 9600 g Tt + £ + : z 8 r20 aa L ‘200 A E t seco Tr as ES & aay i Figure 13—Junction and repair strength results fom hypophysectomized male ratsre ‘moues for six weeks, Means and SE ar Iited. No group hed les than 0 animal. Raa fol, 21144-1180, 1971. ving daily injections of selected hor- data can be found in Am J. Phys-174 “weakest link” and could be the most responsive to the ef- fects of physical activity 4, Junction strength is highly correlated with body weight and poorly correlated with ligament weight. ‘These findings suggest that different mechanisms are re- sponsible for the elfeets of exercise training on junction strength and on ligament weight. 5. The weight/length ratios of ligaments are higher in exercised trained rats and lower in immobilized rats, This difference is not asociated with a change in water con- REFERENCES Lo Anau, A. Elfest of exercise upon ligamentous strength Hes a, 3163-167, 196, 2 Anak Jo. J. Hivate, Kil Kivisxo and O. 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