REVIEWS

Inflammatory mechanisms in
tendinopathy – towards translation
Neal L. Millar1, George A. C. Murrell2 and Iain B. McInnes1
Abstract | Tendinopathy is a multifactorial spectrum of tendon disorders that affects different
anatomical sites and is characterized by activity-related tendon pain. These disorders are
common, account for a high proportion (~30%) of referrals to musculoskeletal practitioners and
confer a large socioeconomic burden of disease. Our incomplete understanding of the
mechanisms underpinning tendon pathophysiology continues to hamper the development of
targeted therapies, which have been successful in other areas of musculoskeletal medicine.
Debate remains among clinicians about the role of an inflammatory process in tendinopathy
owing to a lack of clinical correlation. The advent of modern molecular techniques has
highlighted the presence of immune cells and inflammatory mechanisms throughout the
spectrum of tendinopathy in both animal and human models of disease. Key inflammatory
mediators — such as cytokines, nitric oxide, prostaglandins and lipoxins — play crucial parts in
modulating changes in the extracellular matrix within tendinopathy. Understanding the links
between inflammatory mechanisms, tendon homeostasis and resolution of tendon damage will
be crucial in developing novel therapeutics for human tendon disease.

Enthesopathy
Injury to the enthesis, the
portion of tendon at the
bone–tendon junction site.
TNFΔARE mice
Mouse model in which
systemic overexpression of
TNF leads to the development
of inflammation.
1
Institute of Infection,
Immunity and Inflammation,
College of Medicine,
Veterinary and Life Sciences
University of Glasgow,
120 University Avenue,
Glasgow G12 8TA, UK.
2
Orthopaedic Research
Institute, Department of
Orthopaedic Surgery,
St George Hospital Campus,
4–10 South Street Kogarah,
Sydney, NSW 2217,
Australia.
Correspondence to N.L.M.  recent evidence suggests that OA is an active process
neal.millar@glasgow.ac.uk
doi:10.1038/nrrheum.2016.213
Published online 25 Jan 2017
Tendinopathy is a term used to describe a complex mul-
ti-faceted pathology of the tendon characterised by pain,
decline in function and reduced exercise tolerance1,2.
Tendinopathies pose an important clinical problem —
particularly in musculoskeletal and sports-related med-
icine3 — and account for up to 30% of general practice
musculoskeletal consultations. Historically, there has
been considerable disagreement with regard to classifi-
cation and terminology related to tendon disorders. The
term ‘tendonitis’ was traditionally used by rheumatolo-
gists to describe painful symptoms attributed to inflam-
mation of the tendon4 whereas ‘tendinosis’ was used to
reflect degenerative changes at the microscopic level5.
Much controversy has stemmed from sports-­related
tendon disease studies that concluded that there is no
clinical evidence (redness, tenderness, skin changes or
raised systemic inflammatory markers in blood) of a
classic inflammatory event in tendino­pathy and that
a chronic degenerative disorder devoid of an inflam-
matory process prevails. A similar view was taken in
relation to the pathophysiology of osteo­arthritis (OA),
which was attributed mainly to excessive wear and tear 6
and devoid of an inflammatory phenotype7. However,
caused not simply by ageing and cartilage loading but
also by infiltration of inflammatory cells8 (includ-
ing CD4+ T cells and natural killer (NK) cells) and
production of proinflammatory cytokines9. Similar to
tendinopathy, mechanical overload in OA remains a
key driver of pathology but the evidence now suggests
it is mediated, at least in part, through elements of the
inflammatory response10.
Furthermore, recent musculoskeletal scientific atten-
tion has focused of the immunobiology of the enthesis11,
the connective tissue between tendon or ligament and
bone. Enthesopathy has been considered analogous to
tendinopathy as both the enthesis and tendon are sites
of high mechanical stress12. Interestingly, the enthesis
contains a unique population of resident T cells, which,
when activated by the cytokine IL‑23, can promote
pathogenesis that is characteristic of spondyloarthritis13.
Additionally, TNFΔARE mice (which provide a translational
spondyloarthritic model)14 show that enthesitis (inflam-
mation of the enthesis) is driven by mechanical strain
and resident stromal cells, two facets that are dysregu-
lated in tendinopathic lesions15. Similarly, advances in
tendon biology have increasingly recognized that a lack
of observation of an acute inflammatory infiltrate does
not exclude a role for inflammation in the pathogenesis of
tendinopathy throughout the spectrum or kinetics of the
disease16. Inflammation in immunological terms may be
defined as a signal-mediated response to cellular insult 17.
The inflammatory response protects the body against
injury and can promote healing but can itself become

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Key points I trials showing no efficacy compared with saline26,27.

• Tendinopathy is a complex multi-faceted tendon pathology commonly associated
with overuse
• Most current treatments for tendinopathy are neither effective nor evidence-based
• Many recent studies have highlighted inflammatory cell infiltrates in both animal and
human tendon disease
• The potential roles of inflammatory mediators acting on the resident tenocytes are
the source of some controversy and require in‑depth investigation using in vitro and
in vivo models
• Understanding the key inflammatory pathways affecting extracellular matrix
regulation and homeostasis are critical in designing future targeted therapies
for tendinopathy
dysregulated with deleterious consequences. It is now
increasingly evident that inflammatory mechanisms and
the innate immune system are activated within the ten-
don matrix microenvironment during tissue injury and
probably contribute to dysregulated homeostasis18. This
Review aims to consolidate and interpret the inflam-
matory molecular events involved in tendinopathy, and
analyse how this information might best be utilised to
transform the management of human tendon disease.
Clinical features of tendinopathy
The absence of pain and functional limitation makes
the diagnosis of early tendinopathy difficult (FIG. 1).
Tendinopathy is clinically diagnosed after gradual onset
of activity-related pain, decreased function and some-
Mid substance times localised swelling, and clinical examination reveals
Midportion of a tendon.
pain with stretching and palpation of the pathological
Eccentric contraction area15,19. Ultrasonography and MRI are extremely helpful
Phase of contraction that in formulating a diagnosis while additionally differen-
occurs as the muscle tiating between mid substance versus enthesial tendi-
lengthens.
nopathy and assisting surgical planning. Treatments
Isometric contraction commonly commence with physical therapy, which
Type of contraction during itself has moved from the use of pure ‘eccentric’ training
which muscle length does not programmes20 towards ‘isometric’ exercise, which has
change (as opposed to been shown to reduce initial pain followed by eccen-
concentric or eccentric
contractions).
tric retraining of tendon21. Robust systematic evidence
continues to support first-line physiotherapy treatment
Extracorpeal shockwave with between 53–86% improvement in the symptoms22.
therapy Additionally, physiotherapy modalities such as ultra-
Use of high-amplitude pulses
sound, laser therapy, hyperthermia and extracorpeal
of mechanical energy, similar
to soundwaves, to treat shockwave therapy (ESWT) have been advocated; how-
tendinopathic lesions. ever, evidence to support their widespread use in all
tendinopathies remains inconsistent 23. Oral NSAIDs
Debridement have been used extensively for decades to treat pain asso-
Surgical removal of
degenerative tendon tissue.
ciated with tendon overuse. Whereas evidence suggests
that both oral and locally administered NSAIDS are
Microcautery effective in relieving the pain associated with tendino­
Micro-debridement of diseased pathy in the short term (7–14 days), their efficacy in the
areas of tendon tissue using a
treatment of chronic tendinopathy is unclear 24. Platelet-
high-temperature fine-tipped
instrument. rich plasma (PRP) is a blood derivative that contains
high levels of growth factors (platelet-derived growth
Fibrocartilaginous change factor, vascular endothelial growth factor and cytokines
A process in which such as IL‑6, IL‑8 and IL‑1β) that can promote tissue
chondrogenesis occurs in an
area of tendon and the
healing in vitro 25 and has quickly been adopted into
structure of the cells changes the clinically arena. However, the benefits of PRP for
to chondrocytes. tendinopathy remain controversial, with several level
Stem-­­­cell-­based therapy has improved tendon healing
in equine tendinopathy 28 but effective translation to
humans has yet to materialise. Importantly, in an era
of increased regulatory oversight of medical devices
and pharmaceuticals29 none of the recent ‘novel’ tendi-
nopathy treatments (such as PRP or stem-cell-based
therapy) have provided mechanistic insight; thus, their
wholehearted adoption in the clinical community is not
yet apparent. Surgical options including debridement
and microcautery remain the last option owing to their
morbidity and inconsistent outcomes30.
Tendinopathy pathophysiology
The primary function of a tendon is to enable transduc-
tion of mechanical forces from the muscle to bone31. The
high tensile strength of tendons is derived from a strictly
linear arrangement of collagen fibrils formed as a result
of covalent cross-linking of collagen molecules. The
main component of tendons is type I collagen, which
accounts for approximately 60–85% of the dry weight
of the tendons, with the remainder made up of proteo­
glycans, glycosaminoglycans (GAGs), glycoproteins
and other collagen types (III, XII, V)2,32. Tenocytes are
fibroblast-like cells that make up the basic cellular com-
ponent of tendon tissue and are found uniformly aligned
between collagen fibrils33. Tenocytes react to external
stimuli to regulate the synthesis and turnover of extracel-
lular matrix (ECM) components facilitating functional
adaptation in response to altered mechanical load34,35.
The pathological features of tendinopathy have
been described in many studies over the past 30 years36.
Changes in the ECM in tendinopathy are character-
ised by a loss of collagen organization, fibrocartilagenous
change with deposition of additional ECM protein (such
as GAGs)37,38. Importantly, type III collagen is produced
in the initial phases of tendon damage39 as a conserved
mechanism to provide a rapid ‘patch’ to the area of
damage. Type III collagen is laid down in a haphazard
fashion, contributing to the irregular alignment seen
microscopically and translating to inferior biomechani-
cal strength in damaged tendon40. In the normal tendon,
type III collagen is gradually replaced by type I collagen,
which resumes the linear structured arrangement with
eventual resolution to normal tendon ultrastructure41.
Microscopically, tenocytes become rounder (enlarged
lysosomes), more proliferative and apoptotic before
the development of tendinopathy 42–44. At the electron-­
microscopic level, collagen fibres in tendinopathic ten-
dons are angulated, vary in diameter, and have buckling
of the ECM45 consistent with poor structural integrity.
Additionally, increased neovascularisation has been
previously thought to represent a classic pathological
feature of tendinopathy 23,46; however, evidence now sug-
gests that this is probably part of a complex interaction
with neoinnervation and may represent homeostatic
remodelling 47,48.
Theories about the pathophysiology of tendino­pathy
postulated thus far are varied, probably not mutually
exclusive and largely unproven15. The mechanisms
include dysregulated apoptosis49, mechanical overload50,

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Paratenon Epitenon Endotenon Collagen Tenocyte

fibre

Collagen fibril

Fascicle

Pathology
• Mucoid degeneration
• Neovascularization
• ↑ Type III/type I collagen ratio
• Apoptosis

Normal Tendinopathic

Clinical features
• Pain
• Swelling
• Loss of function

Treatments
• Physiotherapy
(isometric, eccentric)
• Oral analgesia, NSAIDs
• Orthotics
• Injections
• Shockwave therapy
• Surgery

Figure 1 | Pathological and clinical features of tendinopathy. Schematic representation of the microstructure of normal
tendon showing collagen fibril structure and tenocytes in homeostatic tendon. The main Nature pathological features
Reviews of
| Rheumatology
tendinopathy include mucoid degeneration, loss of parallel collagen fibril structure, increased neovessels, changes in
type III to type I collagen ratio and cell death (apoptosis). Importantly, there is a ‘switch’ in collagen production from the
predominant type I collagen (95% in normal tendon) to the biomechanically inferior type III collagen (5% in normal
tendon), which is increased by ~30% in tendinopathic tissues. Cardinal clinical signs include pain, fusiform swelling and
loss of function, particularly in sporting individuals. Treatments range from physiotherapy (isometric and eccentric
exercises) aiming to reduce pain by loading the tendon back to a homeostatic state, to pain relief with NSAIDs and
local corticosteroid injections. Surgery (tendon release and debridement, microcautery) remains possible for
recalcitrant situations with more-recent therapies including shockwave therapy and platelet-rich plasma injections
whose evidence base remains limited.

imbalance in the equilibrium between the activity of
matrix metalloproteinases (MMPs) and tissue inhibitors of
metalloproteinases (TIMPs)1, genetic factors (such as pol-
ymorphisms in COL5A1 (encoding type V collagen) and
MMP8)51, neuronal proliferation52 and inflammation53,54.
One of the major limitations of human studies on tendin-
opathy is that tendon biopsy samples are usually obtained
when patients are sufficiently symptomatic to require sur-
gery and therefore such biopsy­obtained material is likely
to represent chronic rather than early-phase disease55.

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techniques, a clear signature defining inflammatory

Blood vessel
Infiltrating compartment
• Immune cell differentiation
M1 • Cytokine and chemokine
Mϑ
production
Infiltrating
mast cell Macrophage Proinflammatory Pro-resolving
macrophage M2
Infiltrating T cell macrophage
Collagen fibres
Resident Stromal compartment
macrophage • Matrix regulation,
Tenocytes inflammatory crosstalk
• Cytokine and chemokine
Resident mast cell production
Immune-sensing compartment
• DAMP and PAMP recognition
• Cytokine and chemokine production
Figure 2 | Immunobiology of tendinopathy. Inflammation in tendinopathy
encompasses three distinct compartments involved in a NaturecomplexReviews
network| Rheumatology
of
downstream effects with consequences for tendon homeostasis. The infiltrating
compartment includes influxing immune cells: T cells, mast cells and macrophages
(proinflammatory (M1) versus pro-resolving (M2)) probably recruited through stromal
and resident immune cell activation that, in normal circumstances, represents a
homeostatic inflammatory response but is aberrant in tendinopathic disease. The
immune-sensing compartment comprises tendon-resident innate cells (mast cells and
macrophages) that act as sentinels to respond to initial tissue insult through
damage-associated or pathogen-associated molecular patterns (DAMPs and PAMPs,
respectively) and become activated via downstream cytokine signalling. Finally, the
centrally placed resident tenocytes sit in the influential stromal compartment, which is
responsible for tissue remodelling and repair. Tenocytes secrete cytokines and
chemokines in either an autocrine or paracrine way due to the presence of cell-surface
immune receptors and can be driven toward an activated inflammatory phenotype.
These three compartments contribute to interactions between the inflammatory
response and the extracellular matrix in diseased tendon, which in turn comprise a
balance between reparation versus further degeneration within the tendon.
Additionally, purported theories on the pathophysiological
mechanisms involved in tendinopathy have changed over
time. For example, the ‘continuum’ model that describes
reactive tendinopathy, tendon disrepair and degenerative
tendinopathy reports no inflammation-meditated change
throughout the course of these injuries56, whereas the
‘failed healing’ theory defines inflammatory responses
throughout the course of tendinopathy (injury, failed
healing, and clinical presentation)57.
Inflammation in tendinopathy
Disparate views surrounding the presence of an inflam-
matory phenotype in tendinopathy have persisted pos-
sibly as a result of several historical studies highlighting
Patellar tendinopathy
A common overuse injury,
no inflammatory cells or acute inflammatory infiltrates
caused by repeated stress on (from polymorphonuclear cells) in various human tissue
the patellar (kneecap) tendon. specimens58–60. With the advent of modern molecular
mechanisms has become apparent in the spectrum of
tendinopathic disease in both animals and humans61–64.
One of the most clinically and functionally relevant
classification systems for tendinopathy remains that
of Martin Blazina through his original work on patel-
lar tendinopathy62. This classification system divides the
chronology of symptoms into acute (when symptoms
are present for 0–6 weeks), sub-acute (6–12 weeks)
and classic chronic tendinopathy (when symptoms are
present for more than 3 months). Molecular evidence
suggests that many of the key inflammatory interac-
tions occur in the earlier (acute and subacute) stages of
repetitive tendon microtrauma when patients may be
asymptomatic, which could account for the disparate
views between healthcare professionals and the scien-
tific community 63. At these early stages, changes in tissue
microenvironment and activation of the innate immune
system interact at a crossroads between reparative ver-
sus degenerative ‘inflammatory’ healing. Additional
evidence suggests that repetitive biomechanical stress
and its associated damage in stromal tissues plays a key
part in the immune system response to regeneration64.
Therefore, it seems that inflammation in tendinopathy
encompasses three distinct cellular compartments (stro-
mal, immune-sensing and infiltrating compartments),
each contributing to a complex milieu of inflammatory
mechanisms effecting tendon homeostasis (FIG. 2).
The stromal compartment
The most abundant cells of the stroma are tenocytes,
which are responsible for tissue remodelling and repair.
Literature supporting a critical role for tissue stroma in
further defining the phenotype and outcome of inflam-
matory responses is rapidly increasing 65. Given the rel-
ative paucity of primary tenocyte studies, we consider
that a comparative approach with another musculo­
skeletal disease, such as rheumatoid arthritis (RA),
may be informative. RA synovial fibroblasts (RASFs)
exhibit anchorage independence, semi-autonomous
proliferation and altered ECM synthesis, and can pro-
duce inflammatory cytokines and chemokines66 (such
as IL‑8, CCL5, and growth-regulated alpha protein
(CXCL1)) that recruit and activate leukocytes in the
synovial compartment. Thus, RASF activation results
in the accumulation, survival and retention of leuko-
cytes at sites of disease, mimicking the microenviron-
ment seen in lymphoid tissues, and thereby promoting
chronic inflammation. Moreover, RASFs that are iden-
tified by expression of the markers podoplanin (PDPN)
and transmembrane receptor CD248 have been shown
to drive aberrant tissue damage67. This work has been
reproduced in tendinopathy whereby biopsy-obtained
samples of diseased tendon showed increased CD248
and PDPN expression and cytokine (IL‑1β, IL‑6, IL‑8)
stimulation drove the resident stromal tenocyte toward
an activated PDPN+CD248+ inflammatory phenotype68.
We therefore propose that resident tenocytes possess the
capacity to behave similarly, perhaps in response to tissue
damage components recognized via damage-associated
molecular patterns (DAMPs) and pathogen-associated

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Alarmins
Molecules released from a
damaged or diseased cell that
stimulate an immune response.
Full-thickness rotator
cuff tears
Tearing of one or more of the
rotator cuff tendons whereby
the tendon no longer fully
attaches to the head of the
humerus.
molecular patterns (PAMPs), or other alarmins. Thereby,
subsequent immune-stromal cell–matrix interactions
could have an important role in the failed resolution
of an inflammatory response in normal mechanically
loaded tendons leading to chronic persistent disease that
would manifest as tendinopathy.
The immune-sensing compartment
In tissues, macrophages and mast cells act as immune
sentinels in the front line of tissue defence, discretely
positioned and transcriptionally programmed for
detecting and responding to initial tissue damage.
Increased accumulation of macrophages and mast cells
has been reported in a rodent model of upper extrem-
ity overuse69 and a calcaneal tendon overuse model70,
respectively. Frequently, macrophages have been func-
tionally grouped into two classes: M1 and M2. This con-
cept has often been over-interpreted as a rigid functional
classification of macrophages and not, as it was seem-
ingly intended, as a simplified operational concept 71.
M1‑polarized (classically activated) macrophages seem
to show a proinflammatory response pattern, whereas
M2 (alternatively activated) macrophages dampen
inflammatory responses by producing immuno­
suppressive cytokines such as IL‑1 receptor antagonist
(IL‑1Ra), IL‑10, IL‑4 and IL‑13 (REF. 72). Per this model,
tissue-resident macrophages are classified as M2‑like,
with fundamental roles in tissue homeostasis that relate
to the role of macrophages during development, main-
tenance of homeostasis and resolution of inflamma-
tion73. Pan macrophage (CD68) and M2 macrophage
(CD206) markers have been described in equine 74
and human75 tendinopathy in early and late stages of
the disease. Mast cells have been found throughout the
spectrum of normal and tendinopathic human ten-
don disease76. Mast-cell-derived immune mediators
modulate collagen synthesis and MMP expression in
human tenocytes77, reflecting their probably impor-
tant homeostatic role in matrix regulation within this
compartment.
The infiltrating compartment. This compartment
comprises an influx of immune cells, their subsequent
downstream cytokine production and the effect of
inflammation and ECM crosstalk that determines rep-
aration versus degeneration. Surgically induced tendon
injury elicited a sequential pattern of inflammatory cell
infiltration, consisting of a rapid and transient accumu-
lation of neutrophils, followed by an increase in macro­
phage infiltration between 1 and 28 days post-injury
in a rat model of Achilles tendon injury 78. A systemic
review of the presence of immune cells in human
tendinopathy has shown increased macrophages (four
studies) and mast cells (three studies) in tendinopathic
versus healthy tissues79. We previously suggested non-
torn subscapularis tendon in patients with full-thickness
rotator cuff tears as an ‘early model of tendinopathy’ on
the basis of histological appearance and substantially
increased levels of cytokines and apoptotic markers80.
This observation, in turn, likely reflects the earliest
impact of altered biomechanical loading whereby the
tendon is stressed, providing a molecular signature
for early human disease. Moreover, other studies have
revealed the presence of NK cells and T lymphocytes
in tendinopathic and normal human tendon biopsy
samples81,82, which suggests that the infiltrating cell
population may be more immunologically active than
previously thought.
Molecular mechanisms of inflammation
It is increasingly clear that interactions between immune
cells (either resident or infiltrating) and resident stromal
cells have important roles in turning a spontaneously
resolving inflammatory response within tendon tissue
into a chronic disease with ultimate tissue degeneration.
As with other musculoskeletal pathologies, the ability
to sample human tissue that truly reflects the molecu-
lar mechanisms driving disease in terms of location and
time remains a challenge. Therefore, animal models of
tendinopathy may improve our understanding of human
tendinopathy and its underlying pathology. However,
current animal models present advantages and limi-
tations, and there remains no consensus regarding the
criteria of an universal tendinopathy animal model83.
Notwithstanding the limitations of such models, we shall
now consider the current range of inflammatory mole-
cules in both animal and human models of disease (FIG. 3)
that may play a part in the stromal microenvironment
leading to tendinopathic features. For clarity and subse-
quent translational utility, we have taken a reductionist
approach in describing individual candidate effector
moieties. It is vital to recall that inflammatory responses
comprise complex multi-cellular responses coordinated
by groups of mediators operating in a coordinated system
rather than in isolation.
Cytokines
Cytokines remain the most investigated inflammatory
mediators in tendinopathy, probably owing to their crit-
ical interactions with the resident tenocytes, ECM and
immune cells, and the extent of suggestive cytokine effec-
tor biology gleaned from other musculoskeletal disease
pathologies (TABLE 1).
IL‑1 family signalling. The IL‑1 superfamily of cytokines
are important regulators of innate and adaptive immu-
nity, playing key parts in host defence against infection,
inflammation, injury and stress. IL‑1β is released by
tendon cells in response to mechanical stretching 84,
whereas the addition of IL‑1β to tendon cells in vitro
results in the production of proinflammatory molecules,
such as prostaglandin G/H synthase 2 (also known as
cyclooxygenase‑2 (COX‑2)), MMP1, MMP3 and EP4
receptor for prostaglandin E2 (PGE2)85. Importantly,
IL‑1β downregulates considerably the expression of
type I collagen mRNA in human tenocytes thus linking
inflammation and ECM remodelling. In addition, IL‑1β
selectively stimulates the expression of PGE2 in human
tenocytes, which may lead to ECM degradation in the
tendon86. Proteomic analysis of equine tendinopathy has
shown ECM cleavage fragments in early stages of tendon
disease generated by an IL‑1β‑mediated mechanism87.

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IL-33 IL-6
Type III collagen regulation Collagen synthesis
IL-4
IL-4R Reduced tendon strength
IL-33
IL-6 IL-6R
IL-1 IL-1RAcP ST2L IL-4
Reduced tendon IL-4Rα IL-13
strength IL-13R Tenocyte
IL-1β γC
proliferation
IL-1R1 IL-13
gp130 JAK1 IL-4Rα
miR29a IL-13Rα1 IL-21R
TNF MyD88 P JAK3
Tenocyte activation STAT6 Tenocyte
TYK1 JAK1 IL-13Rα2 activation
IRAK
TNF P
TRAF6 MAPK STAT6 IL-21R
STAT3
TNFR ERK, p38, JNK TYK2

TRAF2 • Inflammation STAT3

• Collagen remodelling
NF-κB COX2 • Cell proliferation Tenocyte
TRAF6 • Neoangiogenesis

IL-17R
EP2/4

IL-17A, IL-17F
FPR2
PGE2
LXA4
IL-17 15-epi-LXA4
Apoptosis
Cytokine induction LXA4 PGE2 Inflammatory/
Type III collagen Tenocyte activation Tenocyte proliferation matrix crosstalk
Figure 3 | Inflammatory mechanisms in tendinopathy. This figure highlights the potential targetable intracellular
signalling pathways that have functional consequences (such as regulation of extracellular matrix (ECM), immune cell
recruitment and cell proliferation) relevant to tendon pathology. For example, activation of mitogen-activated protein
Nature
kinase (MAPK) signalling by the cytokines IL‑33 (through myeloid differentiation primary Reviews
response | Rheumatology
protein MyD88, IL‑1
receptor-associated kinase (IRAK) and TNF receptor-associated factor 6 (TRAF6)), IL‑6 (through p130) and IL‑17
(through TRAF6); activation of nuclear factor κB (NF‑κB) signalling by TNF (through TRAF2) or 15‑epi-lipoxin A4
(15‑epi‑LXA4); and activation Janus kinase (JAK) and signal transducer and activator of transcription (STAT) by IL-13
result in downstream mediation of enhanced cytokine and chemokine production, ECM remodelling (collagen and
other proteins), proliferation and angiogenesis, all of which become dysregulated in tendon disease. Appreciation of
these pathways could help define the molecular checkpoints that modify a homeostatic inflammatory response toward
an aberrant inflammatory tendon microenvironment that leads to clinical tendinopathy. An ideal tendinopathy target
should modify the proinflammatory response and promote resolution by sparing inflammation-induced healing
moieties and encouraging robust and rapid matrix repair. COX, cyclooxygenase; EP, prostaglandin E2 receptor; FPR2,
N-formyl peptide receptor 2; PGE2, prostaglandin E2.

A further IL‑1 family member, IL‑18, has been identi-
fied at mRNA and protein levels in human supraspinatus
tendinopathy samples53.
Another IL‑1 homologue, IL‑33, is released following
cellular damage88 and biomechanical overload89, and has
been implicated in a variety of inflammatory patholo-
gies90. We observed elevated IL‑33 expression in early
human tendinopathy compared with both established
tendinopathy and intact control tendon91. Addition of
recombinant human IL‑33 (rhIL‑33) to human tenocyte
cultures in vitro resulted in increased expression of both
mRNA and protein levels of type I collagen and, par-
ticularly, type III collagen, with an associated increase in
protein expression of IL‑6, IL‑8 and monocyte chemo­
attractant protein‑1 (CCL2). These IL‑33‑induced
changes in levels of expression of collagen and cytokines
were abrogated by NF‑κB inhibition, suggesting that
IL‑33 operates in tenocytes via a canonical IL‑1 receptor
(IL‑R) signalling pathway. In an in vivo patellar tendon
injury model, intraperotineal injection of rhIL‑33 did
not affect synthesis of type I collagen but increased
type III collagen synthesis considerably, particularly
in injured tendons91. Moreover, rhIL33 administration
markedly reduced ultimate tendon strength at all the
time points post-injection, suggesting that such changes
were of functional impact. Conversely, in St2−/− mice
(which lack the St2 gene (also known as Ll1rl1) encod-
ing the IL‑33 receptor), rhIL‑33 administration did not
affect collagen ECM synthesis or ultimate strength of
the healing tendon, which confirmed that IL‑33 acted
via an ST2‑dependent pathway. Neutralizing antibodies
directed against IL‑33 attenuated the type I collagen to
type III collagen switch at days 1 and 3 post-injury in
injured wild-type mice resulting in a substantial increase
in biomechanical strength of the tendons of wild-type
mice at day 1 post-injury. Targeting IL‑33 or ST2 the

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Table 1 | Cytokines implicated in tendinopathy proinflamatory and immunoregulatory cytokines102, and

Cytokines Proposed function in tendinopathy
IL‑1β ECM remodelling, reduced type I collagen production84,85
IL‑18 ECM remodelling and immune cell recruitment53
IL‑33 ECM remodelling, increased type III collagen and cytokine production 91
IL‑6 Increased total collagen synthesis, cytokine feedback94,95
TNF family Reduced type I collagen, increased proinflammatory cytokine
production53,104
IL‑21R Proinflammatory cytokine induction111
IL‑17 ECM remodelling, increased type III collagen production, tenocyte
family apoptosis and cytokine production97,114
IL‑4 • Reduced tendon strength in Il4−/− mice95
IL‑13 • ECM remodelling107
IL‑15 • ECM remodelling and immune cell recruitment53
ECM, extracellular matrix, IL‑21R, IL‑21 receptor.
has been posited as a potential therapeutic approach for
autoimmune diseases such as RA90 with first‑in‑human
dosing of an anti‑IL‑33 antibody (ANB020) enter-
ing phase I clinical trials92. The safety and tolerability
observed in these trials will probably guide potential
applications in patients with chronic tendinopathy.
IL‑6 signalling. IL‑6 is a pleiotropic cytokine with a
wide range of biological activities in immune regula-
tion, haematopoiesis, inflammation and oncogenesis93.
Cyclic tensile strain increases expression of type I collagen
and IL‑6 in tendon fascicles from bovine foot extensors
whereas cyclic loading increases IL‑6 expression in equine
superficial digital flexor tendons94. Patellar tendon injury
in Il6−/− mice show a trend towards lower angular devi-
ation (more organized, normal tendon structure) and
a much higher modulus (greater overall strength)95.
Array data from human tendinopathic tissues from var-
ious anatomical sites have shown that cyclical loading of
tenocytes96 increases IL‑6 production whereas damaged
tendons show aberrant regulation of the IL‑6 pathway,
including decreased expression of IL‑6R and upregula-
tion of its intracellular regulator signal transducer and
activator of transcription 3 (STAT3)97. In humans, pro-
longed running exercise results in concomitant increase
of the concentration of IL‑6 and collagen synthesis in
the peritendinous tissue98. IL‑6 and IL‑8 concentrations
can increase immediately after ESWT and remain sig-
Cyclic tensile strain nificantly elevated for 4 h post-ESWT99. Thus, it seems
The distribution of forces
that change over time in a
likely that IL‑6 delivers both proinflammatory and
repetitive fashion. anti-inflammatory effects in tendon disease similar to
those seen in muscle pathology 100.
Cyclic loading
The application of repeated
TNF. Tendinopathy affecting the equine superficial digital
stresses, strains or stress
intensities. flexor tendon is associated with increases in both protein
and mRNA levels of TNF and TNF receptor 1 (TNFR1) in
Nociceptors tendon tissue101, whereas TNF mRNA is increased 11‑fold
Sensory nerve cells that when torn supraspinatus tendon is compared with con-
respond to damaging or
potentially damaging stimuli
trol tendon obtained during shoulder surgery 53. Cultured
by sending signals to the human tenocytes treated with TNF reduce their type I
spinal cord and brain. collagen deposition and highly upregulate expression of
culturing tendon explants in the presence of TNF leads
to upregulation of the expression of Toll-like receptor 2
(TLR2) mRNA103. Additionally, increased expression of
the TNF receptors in human Achilles tendon was noted
at mRNA and protein levels104.
IL‑4 and IL‑13. Both IL‑4 and IL‑13 promote acute
inflammatory processes, and their receptors are expressed
on a number of cell types105 and are associated with ECM
homeostasis in many disease models. IL‑4 knockout
(Il4−/−) mice display disorganised collagen orientation
and lower cross-sectional area and mechanical proper-
ties106 in a tendon injury model, whereas levels of IL‑10
and IL‑13 in Il4−/− mice are comparable and even superior
to those of control mice95. Reverse transcriptase quantita-
tive PCR (RT‑qPCR) experiments reveal that mRNAs for
the IL‑4 receptor subunit alpha (IL‑4Rα), IL‑13Rα1 and
IL‑13Rα2, but not the common γ‑chain, are present in all
tested tendon tissues and cultured tenocytes107.
The IL‑21–IL‑21R axis. The IL‑21 and IL‑21 receptor
(IL‑21R) axis is a proinflammatory common‑γ chain
signalling cytokine system that has been associated with
chronic inflammatory disease108,109. Tissue injury results
in upregulation of both IL21 and IL21R mRNA110, and its
downstream signalling pathway, STAT3, has been impli-
cated by tendinopathy array data97. We detected elevated
expression of IL‑21R mRNA and protein in human tendon
samples (in macrophages and tenocytes, in which these
levels were upregulated by proinflammatory cytokines
such TNF and IL‑1β in vitro) but found no convincing evi-
dence of the presence of IL‑21 at mRNA or protein level111.
IL‑17 family. Experimental evidence points to the impor-
tance of the IL‑17 cytokine family in the pathogenesis of
several immunoinflammatory diseases112,113. Recent tran-
scriptomic analysis has highlighted increased expression
of IL‑17F in human tendinopathy biopsy samples97. On
the basis of the aforementioned dataset and plausible bio-
logical profile exhibited by IL‑17A, we hypothesized that
IL‑17A may play a part in tendinopathy. IL‑17A mRNA
and protein expression levels were increased in early
human tendinopathic samples114. Furthermore, in human
tenocytes in vitro, IL‑17A regulated proinflammatory
cytokines, key apoptotic mediators and ECM changes
toward a type III collagen phenotype. The availability
of highly effective anti‑IL‑17A monoclonal antibodies
such as secukinumab and ixekinumab, of proven effi-
cacy in the treatment of enthesopathy associated to axial
ankylosing spondylitis (SpA) and psoriatic arthritis115,116,
renders IL‑17A an especially intriguing potential target
in tendinopathy.
Neuronal inflammatory pathways
Inflammatory responses are modulated by a bidirectional
communication between the brain and the immune sys-
tem117. Inflammatory mediators are released from dam-
aged tissue and can stimulate nociceptors directly 118. PGE2
derived from an arachidonic acid via the COX2 pathway
is released from resident cells in damaged site tissue and

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immune cells to promote inflammation and nociception119.
Both in vivo and in vitro evidence support the hypothesis
that PGE2 plays an important part in the development of
tendinopathy18. Improved structural and material proper-
ties of the patellar tendon were found after PGE2 injection
in vivo 120 and repetitive mechanical strain in human teno-
cytes in vitro increases the production of PGE2 (REF. 121).
Inflammatory mediators have also been linked to the
disturbance of glutaminergic pathways (glutamate is a
major excitatory neurotransmitter in the nervous sys-
tem)122. Microarray analysis of a rodent running model
of tendon overuse showed dysregulation of glutamate sig-
nalling in tendon tissue123. Glutamatergic and inflamma-
tory pathways are active in painful human tendinopathy,
despite there being no significant differences in basic ten-
don histology between painful and pain-free tendons124.
This study showed that differences in specific glutamate
receptors — glutamate receptor ionotropic, kainate 4
(GluK4, also known as KA1), metabotropic glutamate
receptor 2 (mGluR2) and mGluR7 — and inflammatory
cell markers (CD45 and CD206) were associated with res-
olution of pain in rotator cuff tendinopathy 124. Moreover,
a systematic review by the same group, analysing 27 stud-
ies, showed clear evidence of changes in the peripheral
neuronal phenotype in painful human tendinopathy 52.
The excitatory glutaminergic system was substantially
upregulated in seven studies, and four studies revealed
a considerable increase in sensory neuropeptide expres-
sion. Thus, further mechanistic studies investigating the
link between inflammatory and nociceptive mediators
are required to elucidate potential therapeutics that target
tendon pain and inflammatory–matrix interactions.
Nitric oxide
Nitric oxide (NO) is a signalling molecule that has a key
role in the pathogenesis of inflammation125. Following
injury to a tendon, NO is produced by all three isoforms of
nitric oxide synthase (NOS)126: NOS activity is upregulated
in tendinopathy127. In a rat Achilles tendon model, the first
isoform to appear was inducible NOS (iNOS), followed by
endothelial NOS (eNOS) and then brain NOS (bNOS)128.
iNOS was expressed in macrophage-like cells and eNOS
was found in endothelial cells, and all three isoforms were
expressed in tenocytes129. In an exercise-­induced overuse
model of tendon degeneration, iNOS, eNOS and bNOS
mRNAs were overexpressed in the supraspinatus ten-
don of rats subjected to treadmill running for 14 days130.
Expression of all isoforms was confirmed in human tendon
disease from biopsy samples taken during shoulder sur-
gery131. Cultured human tenocytes exposed to exogenous
NO increased total collagen synthesis132 whereas micro­
array analysis showed substantial increases in type I colla-
gen α1, type III collagen α1, type IV collagen α5, biglycan,
decorin, laminin and MMP10 (REF. 133).
Pro-resolving mediators
Specialised pro-resolving mediators, such as lipoxins,
have an important mechanistic contribution to the
inflammation pathways involved in tendon disease.
N‑Formyl peptide receptor 2 (FPR2, also known as
ALX or ALX/FPR2) is expressed by monocytes and
macrophages134 and is central in controlling the duration
and magnitude of the inflammatory response, providing
endogenous stop signals for inflammation135. Resolution
pathways are programmed responses activated during
inflammation, resulting in a switch in lipid mediators
from the dominance of prostaglandins to the lipoxins
to promote resolution of inflammation and the return
of tissues to their normal homeostatic state136. Studies
in equine tendon have demonstrated increased expres-
sion of the pro-resolving receptor FPR274 and the switch
from proinflammatory cytokines to the production of
pro-resolving lipids such as lipoxin A4 (LXA4) during
the early stage of tendon injury. Importantly, expression
of FPR2 decreases with time after tendon injury and
with ageing 137. This work was translated to a human
tendinopathy model system including examination of
supraspinatus tendinopathy samples from patients expe-
riencing pain before and after surgical intervention in the
form of subacromial decompression138. Interestingly,
the pro-resolving proteins FPR2 and chemokine-like
receptor 1 (CMKLR1, also known as ChemR23) were
increased in early-stage disease compared with inter-
mediate and advanced tendinopathy samples. This work
also suggests that tendon-derived stromal cells adopt a
proinflammatory phenotype (expressing interferon reg-
ulatory factor 5 (IRF5), indoleamine 2,3‑dioxygenase 1
(IDO1), p65 and nuclear factor NF‑κB) once exposed
to an inflammatory cytokine milieu that primes the res-
ident tenocytes to become hyper responsive to repeated
exposure to proinflammatory mediators.
Toward ‘translational tendinopathy’
Detailed mechanistic investigation of inflammatory
pathways using the ‘molecule to clinical’ intervention
paradigm has been remarkably successful in other
areas of musculoskeletal therapeutics, most notably in
inflammatory arthropathies. In particular, the advent
of highly specific kinase immunomodulators has
increased the therapeutic armamentarium available
to the practising rheumatologist. Cytokine inhibition
has yielded transformative results for patients with RA
and axial spondyloarthropathies139. Despite increased
understanding of the molecular mediators involved in
tendon disease, successful targeted mechanistic treat-
ments have so far eluded the field. Novel injectable
therapies, such as autologous stem cells and PRP, target
multiple downstream immune regulators with no clear
definite pathway targeting 140,141. It is clear that further
mechanistic work is required across the field to char-
acterise and subtype not only the key innate immune
cells, together with their critical regulatory cytokine
groups, but additionally the resident tenocytes in nor-
mal versus diseased tendon pathologies. For example,
macrophage depletion in healing rodent Achilles ten-
don has been shown to increase tensile strength whereas
M2 macrophage recruitment was correlated with ten-
don regeneration in a validated ovine preclinical tendon
regenerative model142, highlighting the critical role of
macrophages skewing towards an M2 phenotype dur-
ing skeletal muscle regeneration143. Additionally, mast
cells exert proinflammatory effects on human tenocytes

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Table 2 | Potential therapeutic agents targeting inflammatory pathways in tendinopathy

Potential targets Therapeutic agents used in musculoskeletal disease
Cytokines
IL‑1β • Anakinra (IL‑1Ra),
• Rilonacept (soluble IL‑1R that binds IL‑1β, IL‑1α and IL‑1Ra)
• Canakinumab (neutralizing anti‑IL‑1β IgG1 mAb)
TNF Infliximab, etanercept, adalimumab, certolizumab pegol and golimumab (anti-TNF mAbs)
IL‑6 • Tocilizumab, sarilumab, clazakizumab (anti‑IL‑6R mAbs)
• Sirukumab
IL‑17 Secukinumab, ixekizumab, brodalumab (anti‑IL‑17A mAbs)
IL‑33 ANB020 (anti‑IL‑33 antibody) in phase I trials
Small-molecule inhibitors
JAK–STAT signalling Tofacitinib and baricitinib (JAK inhibitors)
Resolution pathways
15‑epi‑LXA4 Aspirin
microRNA
miR‑29, miR‑210 MRG‑201 (synthetic miRNA‑29b mimic) and synthetic miR‑210 in preclinical studies
15‑epi‑LXA4, 15‑epi-lipoxin A4; IL‑1R, IL‑1 receptor; IL‑1Ra, IL‑1 receptor antagonist; IL‑6R, IL‑6 receptor; JAK, Janus kinase;
mAb, monoclonal antibody; STAT, signal transducer and activator of transcription.

whereas adipose-derived mesenchymal stromal cells describing the role for hypoxic tissue stress in human
co‑cultured with M1 macrophages successfully sup- tendinopathy showed that ERK and p38 inhibitors
pressed the effects of M1 macrophages on human teno- reduced proinflammatory cytokine/chemokine produc-
cytes by inducing a phenotypic switch from a M1 to M2 tion but did not modulate apoptosis in tenocytes148.
phenotype144. Thus, immune cell manipulation towards NAD-dependent protein deacetylase sirtuin‑1
a regenerative phenotype may provide promising ther- (SIRT1) is required for the inhibition of apoptosis and
apeutic options in tendinopathy. Several molecules inflammatory responses in human tenocytes acting via
(TABLE 2) have been highlighted as potential therapeu- NF‑kB signalling in vitro 149. Importantly, the SIRT1
tic targets in tendon disease. Moreover, appreciation activator resveratrol inhibited NF‑κB inflammatory
of the finely balanced ‘reparative’ versus ‘degenerative’ (COX‑2) and matrix degradation (MMP9) pathways,
inflammatory response in tendon damage is required demonstrating a potential role for resveratrol in the
to identify the molecular checkpoints that modify a treatment of tendinopathy. Curcumin (also known as
homeo­static inflammatory response toward aberrant diferuloylmethane), a naturally occurring polyphenol,
ECM emodelling and the chronic degenerative picture acts via NF‑κB inhibition. In vitro human tenocyte cul-
seen in clinical tendinopathy. tures revealed that curcumin suppressed IL‑1β‑induced
PI3K and p85/AKT activation and its association with
Pathway manipulation NF‑κB essential modulator IKK150. This study pro-
There is considerable interest in the development of posed a potential role for curcumin in treating tendon
highly specific molecules that can modulate intracellular inflammation through modulation of NF‑κB signal-
signal pathways known to confer the exquisite specific- ling, involving PI3K/Akt and the tendon-specific tran-
ity of cellular functions in the context of coordinated scription factor scleraxis in tenocytes. Pharmaceutical
inflammatory responses. Recently, JAK inhibitors have development of small-molecule MAPK inhibitors have
entered clinical use in RA, providing elegant proof of expanded rapidly over the past 5 years with numerous
concept for this approach. phase II trials in RA, all of which failed151,152; however,
Several animal models have highlighted the role of efforts in targeting the upstream JAK family of recep-
mitogen-activated protein kinase (MAPK) signalling tor tyrosine kinases have demonstrated efficacy and
within tenocyte ECM interactions. A rodent model of acceptable safety in RA153. Collectively, therefore, small-­
tendinopathy showed increased extracellular signal-­ molecule inhibitors targeting relevant signalling path-
regulated kinase (ERK) 1/2 signalling 145 whereas a way may provide promising avenues for development of
rodent model of plantaris tendon growth revealed inhi- novel tendinopathy therapies, particularly as inhibitors
bition of p38, which resulted in decreased IL‑6 expres- have several advantages over biologic agents in that they
sion, and had a modest effect on the expression of other can be administered orally and as synthetic compounds
ECM and cell proliferation genes146. ERK1/2 signalling they are comparatively inexpensive to manufacture.
was identified as having a critical role in the mechanism Moreover, by selectively blocking families of cytokine
whereby glucocorticoids inhibit proliferation and colla- effector functions they offer the capacity to modulate
gen synthesis in human tenocytes147. Our previous work integrated cellular regulatory systems in disease.

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Clinical cytokine manipulation IL‑6 significantly stimulated collagen synthesis in the

Carrageenan-induced
tendinopathy
Injection of a family of
carrageenans, linear sulfated
polysaccharides that are
extracted from red edible
seaweeds, directly into a
mouse tendon to establish
tendinopathy.
IL‑1 blockade. In a carrageenan-induced animal tendin-
opathy model the use of IL‑1Ra decreased the develop-
ment of pathological changes154. It also showed marked
reduction in key tendinopathic features including cell
infiltration, angiogenesis and cell density. The main
limitation of this study was the use of an inflamma-
tory induced model system, which may not reflect
the molecular signals of a chronic overuse lesion. A
follow‑up study using a stress-shielded rodent model
showed that IL‑1Ra prevented morphological deterio-
ration and collagen metabolism of Achilles tendon after
stress shielding 155 while IL‑1Ra effectively reduced the
development of mechanical, chemical and histologic
changes seen in carrageenan-induced tendinopathy 154.
Anakinra is a recombinant, non-glycosylated form of
human IL‑1Ra. In a human proof-of-concept study, 10
patients underwent ultrasonography guided, peritendi-
nous injection of anakinra for chronic Achilles tendino­
pathy 156. The investigators noted a substantial increase
in tendon thickness over time but no changes in walking
pain, pain at rest or intratendinous blood flow in the
anakinra group while additionally reporting no tendon
ruptures. This pilot study comprised a non-randomized,
non-blinded and non-controlled design, which limits
its overall interpretation but demonstrates proof of con-
cept that targeting inflammatory cytokines is a testable
hypothesis in chronic human tendinopathy.
TNF. On the basis of the role of TNF in tendinopathy,
to date there has been one experimental medicine trial
using a fully humanised anti-TNF monoclonal anti-
body, adalimumab, which was administered to a group
of 10 athletes with symptomatic unilateral tendinop-
athy for more than 6 months156. Conservative treat-
ment (non-medical and non-surgical) had failed and
all the patients had ultrasonography‑determined spin-
dle-shaped thickening (1 mm) of the symptomatic ten-
don in relation to the asymptomatic tendon. The patients
were treated with ultrasonography‑guided peritendi-
nous injections of adalimumab. Walking pain showed
a trend toward improvement at 7 days and 12 weeks
post-­treatment. Pain at rest was significantly reduced
after 7 days and again showed a trend (P = 0.07) towards
continued improvement at 12 weeks; all patients showed
significantly reduced blood flow in the tendon over the
12‑week study period. Again, this pilot study comprised a
non-randomized, non-blinded and non-controlled design
but provides proof of principle of cytokine targeting in
human tendon disease.
IL‑6. In a small in vivo study assessing changes in the
ECM as a result of recombinant cytokine therapy in
human tendinopathy, levels of type I collagen turnover
markers were measured in 14 healthy male volunteers,
who had recombinant human IL‑6 (rhIL‑6) infused
into the peritendinous tissue of the Achilles tendon in
one leg, with the other leg serving as the control157. The
individuals were randomly assigned to either a resting
group or an exercise group performing a 1‑ h treadmill
run (12 km/h, 2% uphill) before infusion. Infusion of
peritendinous tissue, highlighting the potential of tar-
geting crosstalk between inflammatory signalling and
ECM as a therapeutic approach.
Targeting pro-resolving molecules
Elucidating the cellular mechanisms by which resolu-
tion of inflammation occurs and the key biochemical
pathways associated with return to tissue homeostasis
may open new avenues for therapeutic interventions
across a range of diseases associated with unresolved
inflammation158. Investigation of resolution pathways
in human tendon disease in vitro has been prompted by
the observation of induced gene expression of CD206
and ALOX15 as a consequence of increased levels of
STAT6 in tendon samples from patients with resolu-
tion of symptoms after surgery 138. In the same study a
stable lipoxin isoform, 15‑epi‑LXA4, induced by aspi-
rin, increased the expression of CD206, ALOX15 and
CCL22 mRNA in disease-derived tenocytes treated
with lipopolysaccharides. It is possible that low doses
of aspirin and its metabolites may act by triggering the
expression of anti-inflammatory and pro-resolving
mediators. Accordingly, aspirin-induced lipid mediators
offer potential therapeutics in tendinopathy and merit
future trials.
Novel regulatory pathways in cellular activation
Emerging studies highlight microRNAs (mi­­­RNAs) as
key epigenetic regulators of integrated mammalian cell
functions. Specific mi­­­RNAs have emerged that particu-
larly regulate cytokine networks while orchestrating
proliferation and differentiation of stromal lineages that
determine ECM composition159. mi­RNAs have provoked
considerable interest as regulators of musculoskeletal
diseases, although their precise contributions to com-
plex disease pathways remains uncertain160. miR‑210 has
been reported as a crucial regulator of angiogenesis161, a
key factor in tendon disease, and it accelerated healing of
the tendon when injected into injured Achilles tendons
of rats162. miR‑210 also induced enhanced collagen qual-
ity, abundant vessels and upregulation of expression of
vascular endothelial growth factor, fibroblast growth fac-
tor 2 and type I collagen162. mi­­­RNAs designed and engi-
neered according to genetic sequences of transforming
growth factor β1 (TGFβ1) and injected in the chicken
tendon injury model achieved downregulation of TGFβ1
expression in vitro and in vivo 163. Some compounds can
regulate endogenous miRNA expression, which may con-
fer therapeutic value. One such study demonstrated that
miR‑29b mediated chitosan-induced prevention of ten-
don adhesion after rodent Achilles tendon injury surgery
by regulating the TGFβ1–Smad3 pathway 164.
We investigated the role of miR29a in tendon disease
on the basis of our observations of IL‑33‑mediated ECM
changes in human and rodent models91. We identified
reduced expression of miR‑29a in human tendino­
pathy biopsy samples and demonstrated that its func-
tional reduction leads to development of tendinopathy.
Importantly, in human tenocytes, miR‑29a was only capa-
ble of influencing the expression of type III collagen and

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not type I. These data indicate that miR‑29a‑mediated
regulation of type III collagen transcript stability is the
predominant factor in the observed increase in type III
collagen production. Although it is likely that miR29a
targets other genes in the tendon inflammatory–ECM
mileu44,45, the reintroduction of miR‑29a to the tendon
injury could reverse the collagen switch that remains
a core pathological feature of tendinopathy. mi­­­RNAs
have several important advantages in that they are bio­
developable and comprise known sequences that are
often highly conserved among species, both attractive
features from a drug development standpoint. The recent
initiation of a phase I clinical study of a synthetic miRNA
mimic to miR‑29b (MRG‑201) with possible extension
to patients with cutaneous scleroderma may therefore
lead to future miRNA therapies in tendinopathy.
Conclusions
The precise functional contribution of inflammation in
human tendinopathy is not established among musculo-
skeletal clinicians and the scientific community. In several
musculoskeletal diseases, rationalizing immunobiology
at the tissue mechanistic level has delivered striking
transitional benefit to the patient. The historical dogma
of a lack of inflammation in tendinopathy has been
challenged over the past 10 years. Modern molecular
techniques have clearly identified an inflammatory
phenotype that is present throughout the spectrum of
tendon disease despite the absence of obvious classical
clinical ‘inflammation’ signs. We contend that the cur-
rent lack of targeted therapeutics represents a failure to
properly embrace the potential in molecular and cellu-
lar translational immune biology to deliver for tendino­
pathy patients. An ideal tendinopathy drug should blunt
the proinflammatory response and promote tendon
pathology resolution by sparing inflammation-induced
healing moieties and encouraging robust and rapid ECM
repair. Appropriately applied, modern ‘omic’ techniques
including transcriptome and proteome analysis should
elucidate the key functional pathways implicated in
clinical disease. It is critical for the tendinopathy field to
now embrace such experimental medicine approaches
and move towards trialling therapies based on emerging
molecular candidates.

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Acknowledgements
N.L.M is supported by a Wellcome Trust Postdoctoral
Fellowship (WT100651MA) and grants from Arthritis
Research UK (Ref 21346) and the Royal College of Surgeons
of Edinburgh.
Author contributions
N.L.M. researched data for the article. N.L.M. and I.B.M.
contributed substantially to discussions of the content and
wrote the article. All of the authors reviewed and edited the
manuscript before submission.
Competing interests statement
The authors declare no competing interests.

122 | FEBRUARY 2017 | VOLUME 13 www.nature.com/nrrheum

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