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IRBM 29 (2008) 267–271

Original article

How a daily and moderate exercise improves ligament healing

Mécanismes mis en jeu lors de la cicatrisation ligamentaire – effets d’un
exercice quotidien modéré
A. Benani a , P. Pottie a , M. Fauchet b,c , C. Gossard b , P.k Netter a , P. Gillet a , C. Guingamp a,∗
a UMR 7561 CNRS, laboratoire de pharmacologie, faculté de médecine, université Henri-Poincaré de Nancy-I, B.P. 184, 54505 Vandœuvre-lès-Nancy, France
b MECABIO, association de recherche en biomécanique humaine et cinématique articulaire, 38 bis, avenue du Général-de-Gaulle, 02200 Soisson, France
c UMR 6600, laboratoire de biomécanique et génie biomédical, centre de recherche Royallieu, université de technologie de Compiègne,

B.P. 20529, 60205 Compiègne, France

Received 21 December 2007; accepted 3 March 2008
Available online 2 May 2008

Abstract
Ligaments are strong bands of connective tissue which display high resistance to tension, allowing joint stability. However, sudden twisting
motion and excessive stretching are causes of sprains. Medical managements involve initial symptomatic treatment and secondary rehabilitation
regimen, without beneficial effect regarding the mechanical properties of the tissue. In fact, ligaments never recover their initial resistance to load
tension. In this article, we reviewed the macroscopic and biochemical characteristics of normal and injured ligaments, with a special emphasis on
the role of cytokines and growth factors during the healing process, and on the beneficial effect of a moderate exercise on the scar formation. Indeed,
recent data highlighted: (1) the role of both IL-1 beta and bFGF during the inflammatory state to promote fibroblast and endothelial cell migration
into the wound; (2) VEGF helped capillary growth during the proliferative state; (3) whereas TGF beta expression resulted in the deposition of a
disorganised fibrotic extracellular matrix. In contrast, mechanical stimulation during a moderate exercise inhibited TGF beta expression, improving
the deposition of specific collagen network and the overall ligament healing process.
© 2008 Elsevier Masson SAS. All rights reserved.
Résumé
Comme tout tissu conjonctif, les ligaments présentent des propriétés importantes de résistance aux contraintes mécaniques et contribuent
ainsi largement à la stabilité articulaire. Cependant, des mouvements d’amplitude excessive lors d’une entorse conduisent à une déchirure d’un
ou plusieurs ligament(s). Les traitements actuels consistent d’abord en une prise en charge médicale symptomatique, puis en une rééducation
fonctionnelle, sans que de véritables bénéfices n’aient pu être observés quant aux propriétés mécaniques du ligament atteint. En effet, au terme
de cette prise en charge, un ligament lésé ne retrouve que très rarement ses propriétés mécaniques initiales. Dans cet article, nous décrivons les
caractéristiques macroscopiques et biochimiques des ligaments sains et lésés. Nous accordons une importance particulière aux cytokines et facteurs
de croissance durant le processus de cicatrisation, ainsi qu’aux bénéfices d’un exercice modéré sur le tissu cicatriciel. En effet, des résultats récents
ont mis en évidence, notamment : (1) le rôle de l’IL-1 bêta et du bFGF pendant la phase inflammatoire sur la prolifération des fibroblastes et des
cellules endothéliales et sur leur migration jusqu’au site lésionnel ; (2) le rôle du VEGF sur la croissance capillaire lors de la phase proliférative ;
(3) le rôle du TGF-bêta lors du dépôt d’une matrice extracellulaire fibrotique. À l’inverse, les contraintes mécaniques qui s’exercent sur le ligament
lésé lors d’un exercice modéré s’accompagnent de la disparition de l’expression de TGF-bêta dans le tissu cicatriciel et du dépôt de plusieurs
collagènes dans des proportions plus appropriées. Il s’ensuit la formation d’un réseau de collagènes mieux structuré qui contribue à une meilleure
cicatrisation du ligament lésé.
© 2008 Elsevier Masson SAS. All rights reserved.

Keywords: Growth factors; Cytokines; Mechanical loads; Collagen

Mots clés : Facteurs de croissance ; Cytokines ; Contraintes mécaniques ; Collagène

∗ Corresponding author.
E-mail address: Corinne.Guingamp@medecine.uhp-nancy.fr (C. Guingamp).

1959-0318/$ – see front matter © 2008 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.rbmret.2008.03.001
268 A. Benani et al. / IRBM 29 (2008) 267–271
1. Introduction
Joint function is essential for motion and depends on the
integrity of several connective tissues, that is bone, cartilage,
synovium and ligaments. Each displays specific properties. Bone
supports the body, cartilage spreads mechanical compression
and ligaments stabilize the joint and support high tensions. All
these tissues which have to resist to mechanical loads are made of
a very large extracellular matrix and cells represent a very low
percentage of the tissue volume only. Resistance to mechan-
ical loads depends on the composition and on the proportion
of the main components, collagens, proteoglycans, and water
[1]. Cells are responsive to local and systemic factors [2], as
well as to mechanical factors [3,4], so that they adapt their
metabolism to improve tissue properties according to the situa-
tions (changes in mechanical loading). In the normal conditions,
the few cells face up the physiological changes. However, in the
case of joint traumatism, the low cell density reduces the ability
of the tissue to heal, especially in cartilage [5] and in ligaments
[6]. A degenerative disease called osteoarthritis [7] develops
in articular cartilage, whereas ligament never recover its initial
resistance to tension [8]. Therefore, current sprains may happen.
In addition, the resulting joint laxity may be the cause of shear-
ing stresses on cartilage, and early osteoarthritis can develop
[9].
2. Normal ligament organization
Ligaments are bands of a dense connective tissue made of
a large extracellular matrix and a low cell density [6] (Fig. 1).
Very rare capillaries cross the ligament so that the tissue remains
homogeneous. Indeed, small vessels interrupting the structure
would make it weaker and lesser resistant to the tensions. The
connective membrane called epiligament surrounding the lig-
ament supports the neurovasculature, and has a nutritive role
regarding the unvascular ligament. It also protects it from abra-
sion [10].
Composition of the extracellular matrix is regulated by the
few stretched fibroblasts inserted between the collagen bundles,
which therefore control ligament ability to resist to tensions. For
examples, ultimate tensile stress of patellar ligament in young
adults is 53.4 ± 7.2 N/mm2 [11], and anterior cruciate ligament
display an ultimate load around 2160 ± 157 N [12].
Ligament extracellular matrix consists mainly in collagens
of type I, type III and type V [13]. They arrange to form fibers
of large diameter from 150 to 400 nm, which are aligned in a
parallel fashion to the mechanical forces. Proportions of type I
and type III collagens can respectively rise up to 85 and 15%,
depending on the ligament, specie and age [13]. According to
Riechtert et al. [14], a large amount of type III collagen repre-
sents the ability of the tissue to adapt to increased mechanical
loads. Proteoglycans are detected as minor components in the
ligaments in comparison to collagens. The sulphated molecules
which provide rheologic properties are usually in large amount
when tissues have to resist to high compression, like articular car-
tilage [15]. In tissues resistant to tension like ligament, decorin
is the main proteoglycan [16]. It has a major role in fibrillo-
genesis, limiting the enlargement of collagen fibers by stearic
bulk. Therefore, the lowest decorin concentration, the largest
diameter collagen fibers display [17]. A large sulphated pro-
teoglycan has also been detected in ligaments, which probably
regulates water flux and hydration level [15]. Water (around 60%
of wet weight tissue) also contributes to the mechanical proper-
ties of ligaments [18], by improving ligament creep behaviour.
In addition, ligament functional length is inversely related to the
hydration.
3. Effect of exercise on normal ligament
Only few studies explored the effects of exercise on lig-
ament biochemistry. Changes in collagen concentration were
usually not observed in tendon or ligament in response to exer-
cise [19–21]. An increased proportion of type III collagen could
be noted, reflecting the rapid ability of fibroblasts to chang-
ing mechanical loads [14,22]. Indeed, some authors reported a
simultaneous increase of tendon stiffness (+ 20%) and ultimate
strength (up to 62%) in response to training for some weeks (for
a review, see [20]).
Local factors have been detected in the ligament during
exercise [23–26]. Increased deposition of TGF beta has been
observed in response to local release of prostaglandins. The pro-
inflammatory mediator may reflect fibroblast suffering during
the run, and contribute to reinforce the ligament by stimulating
collagen synthesis to repair the altered fibrils.
4. Ligament healing process and organization of healed
ligament
Healing in the ligament is the result of three successive and
overlapping stages (Fig. 1) lasting from some days to several
months or years [6,8]. The first stage is called the inflammatory
phase, and last some days to up to some weeks. The gap between
the interrupted and retracted collagen bundles is invaded by
inflammatory cells which remove the debris of the injured part
of the ligament. In addition, the released cytokines promote the
capillary growth in the scar tissue, which helps the next prolif-
erative stage. During this phase lasting some weeks to months,
fibroblasts and endothelial cells migrating from the epiligament
proliferate and fill in the gap. The scar tissue is characterized
by a high cell density in comparison to ligament, collagen fibers
randomly oriented, and numerous capillaries. The last long last-
ing stage (from months to years) is called the remodelling phase.
It is characterized by the reduction of cell density, disappearance
of capillaries, and synthesis of high proportion of type I collagen
instead of the type III collagen which was laid down during the
previous proliferating phase. However, injured ligaments usu-
ally never recover their initial composition and properties at the
site of the lesion.
Several abnormalities have been noted in the healing portion
[6]. First, the structure is lesser homogeneous due to persisting
capillaries which developed during the inflammatory and prolif-
erative phases. These capillaries represent an area of weakness
in the neosynthesized tissue. Second, collagen bundles form a
disorganized network with collagen fibers oriented randomly
 A. Benani et al. / IRBM 29 (2008) 267–271 269

Fig. 1. Result of three successive and overlapping stages in the healing ligament.

through the scar tissue. Indeed, the healed portion of the lig-
ament contains a higher proportion of type III collagen [27].
This essential collagen during healing [13] is laid down rapidly
and forms a loosed network which supports the migrating cells,
that is inflammatory cells, endothelial cells and fibroblasts. Even
after several months or years after ligament injury, the propor-
tion of type III collagen is still abnormally elevated. Heterotypic
collagen fibers form which do not align parallel to the mechan-
ical stretching [28,29]. Lesser cross-links establish between the
chains [30], and the structure is therefore weaker. Cross sectional
observations of the collagen fibers showed that their diameter
strongly reduced [31]. This parameter is related to the proportion
of type V collagen and proteoglycans regarding type I collagen.
Both limit the enlargement of collagen fibers [32]. Therefore, the
collagen fibers have a lesser ability to resist to tension. These
changes in the healing ligament are probably the result of an
inappropriate response of the fibroblasts which loose their abil-
ity to adapt their metabolism according to the biomechanical
stimulations.
5. Effect of exercise on healing ligament
5.1. Structural changes
Joints are usually immobilized just after sprain to limit pain
and to avoid further ligament stretching. However, several stud-
ies reported that the absence of joint motion worsened ligament
healing [29,33]. Indeed, immobilisation for some weeks may
result in a marked decrease in tissue mass and sectional area
up to 74%, a reduction of the maximum force of the two third,
and bone resorption within the insertion sites. In contrast, pas-
sive or active joint mobilisation resulted in beneficial effects
[33,34], with reduced pain and earlier return to work, and up to
50% increase of load to failure when joint was mobilized com-
270 A. Benani et al. / IRBM 29 (2008) 267–271
pared to immobilization. This observation may be related to both
thickening and reorientation of the collagen fibers to the loads
[29]. However, intensive exercise may be deleterious, leading
to microdamages in the scar and reducing the tensile modu-
lus of the stretched ligaments in comparison to the immobilized
ones [35,36]. Therefore, additional mechanical stimulations dur-
ing a standardized and moderate exercise would better improve
the healing process. Only few clinical or experimental studies
explored this hypothesis, and the mechanisms responsible of
these changes have not been studied yet.
5.2. Local factor expression
Numerous growth factors and cytokines regulate the com-
plex healing process taking place in ligament or tendon after
injury [37]. In the experimental model that we developed in the
rat which consisted to tear one third of the fibers of the patellar
ligament, exercise did not increased the inflammatory reaction
(not published yet, Fig. 1). Strong labelling for IL-1beta and
for bFGF was noted during a few days, then the cytokine and
growth factor were slightly detected only. These soluble factors
stimulate cell migration into the gap, as well as proliferation of
endothelial cells and fibroblasts [38,39]. This step is essential
for healing, as capillary growth provides oxygen and nutrient to
the cells which have high metabolic activity to regenerate the tis-
sue. Indeed, the use of nonsteroidal anti-inflammatory drugs, by
reducing the inflammatory response, limited the growth of capil-
laries, and worsened the healing process [40]. VEGF which helps
capillary growth has also been detected as soon as the inflam-
matory response reduced [41]. Collagen synthesis started very
early, with TGF beta stimulating the deposition of a loosed extra-
cellular matrix [42]. Using immunohistochemistry, the growth
factor was first detected in the cells, then in the whole extra-
cellular matrix of the scar tissue (not published yet). It probably
contributed to the deposition of collagen, which however did not
form parallel fibers as observed in normal ligament.
Exercise strongly modified the expression of this growth fac-
tor only. Indeed, it was not detected in the scar tissue 20 days
after ligament injury. As the healing ligaments displayed more
elevated amounts of collagen, a higher proportion of type I col-
lagen and lesser amount of type III collagen (not published yet),
we concluded that mechanical loads due to a daily moderate
exercise resulted in collagen synthesis and deposition in a TGF
beta independent pathway, and improving the healing process
as a denser and more homogeneous collagen network formed.
6. Conclusion
Ligaments have very important roles in joint motion, espe-
cially as stabilizers. In this view, they support high level of
tension. The mechanical strains contribute to tissue organization
so that ligaments develop an appropriate structure to be mechan-
ically resistant. After a ligament wound, treatment consist in
joint immobilization, restraining ligament stretching. Accord-
ing to clinical and experimental observations, differentiation of
the migrating fibroblasts depends on mechanical stimulations
[40], probably very early during the healing process. Therefore,
if joint motion is totally restrain, ligament fibroblasts cannot
acquire their phenotype, and they synthesize inappropriate extra-
cellular components. The more prolonged immobilization, the
worsened healing process will occur in the injured ligament.
However, allowing motion may be difficult when joint is painful,
and risk of further ligament stretching is high.
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