Editorial
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Potential biomarkers of skeletal muscle
damage
“ As the health of skeletal muscle is vitally important to both our physical and
­ etabolic well-being, understanding the scope of damaging insults to skeletal
m
­muscle … can guide therapeutic choices and improve the overall quality of life for
those affected.
Why do we need muscle damage
markers?
Skeletal muscle is remarkably resilient, pro-
viding a lifetime of adaptation to stimuli
(including hypertrophy with resistance
activity), and repair from minor ‘exertional
trauma’, myopathy or major damage [1] .
As the health of skeletal muscle is vitally
important to both our physical and meta-
bolic well-being, understanding the scope
of damaging insults to skeletal muscle (e.g.,
statin myopathy) can guide therapeutic
choices and improve the overall quality of
life for those affected. While the need for
myocardial muscle damage biomarkers is
apparent, the obvious question is “why do I
need to assess skeletal muscle damage with a
biomarker? I can feel when my muscles are
damaged.” In contrast to cutaneous pain,
muscle nociceptor stimulation is processed
differently by the CNS. In particular, pain
signals from muscle have a special relay in
the mesencephalon, and are more strongly
inhibited by descending pain-modulating
pathways than cutaneous pain signals [2] .
Ultimately, this means that unlike cutane-
ous pain, which feels ‘sharp and prickling’,
muscle pain is perceived as a cramping, ach-
ing pain; one that is difficult to localize as
it exhibits referral to other deep somatic
­tissues  [2] .
Thus, perceived pain from muscle injury
is highly variable (based on the individual
degree of inhibitory modulation) and is not
often limiting for necessary activity. From
the perspective of a health professional, this
makes understanding muscle pain and its
impact on the patient’s well-being exception-
ally difficult. From a researcher’s perspective,
identifying how much damage has been cre-
10.2217/BMM.13.163 © 2014 Future Medicine Ltd
”
ated with an experimental paradigm (e.g.,
eccentric or resistance exercise) is challeng-
ing, and often relies on questionnaire-based
assessment of the muscle damage, perceived
as muscle soreness.
What markers have historically been
used?
Serum creatine kinase (CK), myoglobin and
lactate dehydrogenase (LDH) have been the
standard biomarkers of muscle damage for a
Irena A Rebalka
number of years. Department of Pathology & Molecular
Medicine, McMaster University,
Creatine kinase 1280 Main Street West, Hamilton,
Creatine kinase is an enzyme that catalyzes ON, L8S 4L8, Canada
the reversible phosphorylation of creatine to
phosphocreatine, and of ADP to ATP [3] .
Elevated levels of CK, measured in blood
serum, are closely associated with muscle cell
damage and muscle-related disease [3,4] . The
degree of serum CK elevation can be helpful
in differentiating different forms of muscu-
lar dystrophy, however, may not be elevated
in some myopathies, may display variable
expression in each stage of the disorder, and
can be lowered as a result of factors such as
Thomas J Hawke
profound muscle wasting [5] . Additionally, Author for correspondence:
differences in both efflux and basal levels Department of Pathology & Molecular
of CK have been shown as a result of gen- Medicine, McMaster University,
der [6] , athletic ability, type, intensity and 1280 Main Street West, Hamilton,
ON, L8S 4L8, Canada
duration of exercise [3] , ethnicity [7] , alcohol
Tel.: +1 905 525 9140 ext. 22372;
consumption [8] and prescription drugs such hawke@mcmaster.ca
as statins [9] , indicating the contribution of
a broad spectrum of factors to elevations in
serum CK levels. While some of the afore-
mentioned sources of serum CK may be
accounted for by actual muscle damage, oth-
ers cannot, and this variability makes it very
difficult to establish a baseline CK concen-
part of
tration for the indication and diagnosis of
Biomarkers Med. (2014) 8(3), 375–378 ISSN 1752-0363 375
Editorial  Rebalka & Hawke
muscle damage and myopathy. Observing high serum
CK levels may not be diagnostic in itself but will lead
to the conduction of other tests in order to adequately
identify myopathy and degree of muscle damage.
Myoglobin
Myoglobin is a monomeric cytoplasmic hemoprotein
that is expressed exclusively in cardiac myocytes and
oxidative skeletal muscle fibers. A simple urinalysis is
able to reveal circulating levels of myoglobin (Mb). Cir-
culating Mb is absent or present in very low concentra-
tions in individuals without muscle damage therefore,
presence in the urine may indicate muscle damage or
myocardial infarction [10] . Mb is a rapid indicator of
muscle damage, appearing in the urine 30 min after
exertion or injury [11] , and can remain increased in cir-
culation for up to five days post-injury [12] . Although
sample collection is very simple, improper sample
preparation can cause inaccurate results of Mb concen-
tration. Mb deteriorates rapidly in urine, and its stabil-
ity can be affected by the pH and temperature of the
sample [10] .
Lactate dehydrogenase
LDH is an enzyme responsible for the reversible con-
version of pyruvate to lactate. LDH is extruded into
the circulation from cells as a result of muscle damage,
but like other biomarkers, has a notable degree of inter-
person variability [3] and the detection levels are much
lower than that of serum CK [13] .
Though CK, myoglobin and LDH levels can be
measured without invasive techniques such as a mus-
cle biopsy, a number of factors contribute to their
variability in circulating levels at rest, and in their
expression postdamage, limiting the viability of their
results.
What are the ideal attributes of a muscle
damage biomarker?
An ideal biomarker of skeletal muscle damage would
demonstrate the following characteristics:
• Be an exclusive product of skeletal muscle;
• Be expressed at minimal levels in an undam-
aged sample. This feature is of vital importance
as baseline readings of muscle damage markers
(i.e., measures taken when muscle is healthy and
undamaged) are often unknown. A diagnostic tool
where a measurable increase in biomarker content
is consistent with muscle damage will allow any
clinician/researcher to note damage without know-
ing the baseline biomarker values of the affected
individual;
376 Biomarkers Med. (2014) 8(3)
• Be increased in a consistent manner, regardless of
the type of muscle damage (trauma vs myopathy
for example);
• Be increased in a manner that directly correlates
with the degree of injury;
• Would have a consistent temporal pattern of
expression in response to injury;
• Be detected in a blood or other accessible body
fluid-based assay system.
Novel biomarkers to consider?
Novel biochemical markers, such as the candidates
identified below, are receiving attention for their high
sensitivity and/or temporal clarity. We acknowledge
that as large-scale proteomics ana-lysis becomes more
commonplace, the number of biomarker candidates
will expand considerably.
Xin
Xin, a cytoskeletal adapter protein, was recently iden-
tified as a novel biomarker of skeletal muscle dam-
age [14] . Although undetectable within the belly of
uninjured skeletal muscle, Xin expression increases
with damage severity in a highly correlated manner
(regardless whether the damage is a result of myopathy
or eccentric exercise in healthy individuals). What’s
more, it has been found that Xin expression following
acute injury consistently peaked at 12 h postinjury at
the mRNA level [15] , and 24 h postinjury at the pro-
tein level [16] . While many of the biomarkers noted are
found in both cardiac and skeletal muscle (striated),
Xin isoforms are differentially expressed (isoform A
is predominant in cardiac and isoform B in skeletal
muscle) allowing for distinction between damage in
these two tissues. If Xin is indeed an ideal biomarker,
future work will elucidate the expression profile of Xin
within the serum, and determine whether the tight
temporal and damage-severity expression patterns still
exist.
Troponin
Serum troponin levels have been used for assessment
of cardiomyocyte injury and skeletal muscle dam-
age for a number of years [3] . Like Xin, troponin has
tissue-specific isoforms allowing distinction between
cardiac and skeletal muscle damage (a feature critical
if one were interested in identifying cardiomyocyte
damage in persons with myopathy). What may make
skeletal muscle troponin (sTnI) an interesting bio-
marker to pursue is that sTnI exists in two isoforms,
slow (ssTnI) and fast (fsTnI), corresponding to slow-
and fast-twitch muscles, respectively. As a general
future science group

damage biomarker, the use of sTnI is hampered by the
disparity [17] ; however, this dichotomy may prove use-
ful if one were to investigate disease or injury states
that specifically target fast- or slow-twitch muscle
fibers [17–19] .
miRNAs
The recent emergence of miRNAs has garnered sig-
nificant attention in both the world of basic science,
and the area of muscle damage biomarkers. These
endogenous, small noncoding RNAs may prove use-
ful as muscle damage biomarkers due to their size,
tissue-specificity and relative abundance and stabil-
ity in the plasma. Of particular interest is the work
of Laterza and colleagues [20] , who demonstrated
that plasma miR133a levels served as a very sensitive
diagnostic measure for detecting damage induced by
skeletal muscle toxicants. The authors noted that the
sensitivity of plasma miR133a was much greater than
that of CK, which was only slightly elevated in one
rodent following this type of injury. Furthermore,
plasma miR133a levels were not elevated when liver
was damaged by toxin injection, indicating tissue
specificity [20] .
References
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Potential biomarkers of skeletal muscle damage  Editorial
Future studies will help to elucidate whether
miRNA expression is a direct or indirect consequence
of muscle damage. Additionally, future studies are
needed to determine whether expression following
various forms of muscle damage follows a specific
temporal pattern.
Skeletal muscle damage biomarkers are critical
tools for healthcare professionals and researchers
alike. Whether it be in clinical trials, research stud-
ies or exercise therapy prescriptions, the use of these
biomarkers will present a sensitive and reliable index
of the degree of muscle injury so the best next steps
may be made.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial in-
volvement with any organization or entity with a financial
interest in or financial conflict with the subject matter or
materials discussed in the manuscript. This includes employ-
ment, consultancies, honoraria, stock ownership or options,
expert testimony, grants or patents received or pending, or
royalties.
No writing assistance was utilized in the production of this
manuscript.
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