Overuse Bone and Tendon Injuries PRIBUTT 143 Slides

Overuse Bone & Tendon Injury Theories of Tomorrow
Stephen M. Pribut, D.P.M., FAAPSM, FACFAS Past President, AAPSM

Clinical Assistant Professor of Surgery George Washington University Medical School
drpribut.com dr.pribut@gmail.com
Friday, August 17, 12
Hang On Tight
Thoughts
If in the last few years you havent discarded a major opinion or acquired a new one, your critical thinking capacity may be broken.
All models are wrong, but some are useful. (George Box)
Where We Are Going

Introduction Old Theories and New (tissue theory) Bone Tendons
15% 10% 25% 10%
Cell Mechanics and Mechanotransduction 40%
And now for something completely different...
Dive Deep & Think Hard

Does it all stop with Newton & Root or McPoil & Kirby? Should we look in the frontal plane or the sagittal? Or should we look deeper? Lets explore general concepts to solve specic problems. Go deeper: Cellular Biomechanics and Signaling Cellular Concepts
Structure creates function Mechanics or enzyme cascade or both?

Dive In, Dive Deep
4 Questions To Answer

Does eccentric stretching work? Why didnt PRP work better than saline for Achilles tendinopathy? How does ultrasound stimulate bone healing? Does mechanics play a role in healing?
More thinkers, theorists and researchers are needed!
How and from where do scientists get ideas?

And where do comedians get their jokes? Ones like Lenny Bruce, George Carlin?
Dreams
Kekule - 1865 theory of resonance of Benzene.
Inspired by day dream.
Literature
Quark - named from Joyces
Finnegans Wake 1963
Murray Gell-Mann chose name in Admitted to perusing the

book, but not reading it role in theory
Feels beauty and elegance plays

Architecture

Donald Ingber, M.D., PhD. Tensegrity as cellular feature inspired by Kenneth Snelsons Needle and Buckminster Fuller Cytoskeleton works through tensional regulation Cell shape regulation (via matrix rmness) alters genetic expression and affects stem cell and cancer cell growth
Einstein
As Newton once said, If I have seen further
and Lorentz among others.
than others, it is because I have stood on the shoulders of giants.
Special relativity built on the work of Maxwell
One View: You didnt build that alone.
The joke was not approved by Einstein.

Break Down the Barriers

Basic Science Chemistry, Physics, Mathematics, Engineering Architecture, Psychology, Environmental Science Exercise Physiology, Nutrition Science,
Pharmacological Sciences
Interdisciplinary Convergence
Biological Sciences
Biochemistry Molecular Biology
Engineering Science
Physical Sciences
Donald Ingber: the boundaries between the living and non-living systems are beginning to break down.
Podiatric Medicine

Divisions Surgery Biomechanics Wound Care Other areas Barriers intra-disciplinary interdisciplinary
Bone & Tendon Maintenance and Healing

Things we know: inuencing factors
Exercise Aging Sleep
Diet Genetics Psychiatric Disorders (some evidence)
Mind & Gait
Gait Revealer of Aging & Alzheimer's
Mayo Clinic: N= 1341, followed over 15 months
Lower cadence, velocity and length of stride correlated with significantly larger declines in global cognition, memory and executive function.
Basel, Switzerland: N= 1153, mean age of 78

gait became "slower and more variable as cognition decline progressed." Cognitively healthy, mild cognitive impairment or Alzheimer's dementia. Those with Alzheimer's walked slower than those with MCI, who walked slower than those who were cognitively healthy.
Mind & Bone
Depression & Bone Risk

Affects 16% of population Meta-analysis - lower BMD Percentage decrease in BMD was 5.9% for the lumbar spine and 6% for the hip 4 of 5 prospective studies on fracture risk concluded that depression was associated with an increase in fracture risk Many patients were taking SSRI drugs Exercise regimen not taken into account
Possible Factors Involved in BMD and Depression

Animal data suggest a relationship between a hyperactive efferent autonomic nervous system and bone resorption. Impairment of the immune system in depression has been documented. Proinammatory cytokines interleukins (IL) 1 and 6 and tumor necrosis factor are high. Cytokines are stimulants of the hypothalamic-pituitaryadrenal axis, which may account for the hyperadrenocorticism observed in depression. Eskandari et al reported a reduction in anti-inammatory cytokine IL-13. SSRIs - have shown increased bone loss in post-menopausal women, increased risk of fracture, and increased rate of falling
Richards JB, Papaioannou A, Adachi JD, Joseph L, Whitson HE, Prior JC, Goltzman D; Canadian Multicentre Osteoporosis Study Research Group. Effect of selective serotonin reuptake inhibitors on the risk of fracture. Arch Intern Med. 2007 January 167(2):188-94. Ziere G, Dieleman JP, van der Cammen TJ, Hofman A, Pols HA, Stricker BH. Selective serotonin reuptake inhibiting antidepressants are associated with an increased risk of nonvertebral fractures. J Clin Psychopharmacol. 2008 August 28(4):411-7. Friday, August 17, 12
Exercise, Mind & Bone
Reduces risk of depression Lowers risk of osteoporosis Seems to lessen risk of hip osteoarthropathy Mechanics - forces, vibration, pulses of exercise and weight bearing impacts cognition and bone formation
Will we kiss tissue stress theory goodbye?
What should we look at?

The 28 types of collagen? Cells? Bacterial ora? Structural mechanics and biomechanics?
Where will this lead us?
Levels Of Concern: Getting Small
Scanning electron micrograph: bone callus of healed complete trabecular fractures in an osteopenic vertebra probably caused by excessive local microdamage. Frost HM. The Microdamage (MDx) Connection. In: Frost HM. The Utah Paradigm of Skeletal Physiology Vol 1. Athens, Greece: ISMNI; 2004;4:208-219. Copyright 2004, ISMNI.
Looking Back
Thinking Too Narrow
lower extremityspecic theories
Root Biomechanics Nigg proprioception-vibration new paradigm Sagittal plane biomechanics STJ-axis position
Less narrow: Tissue Stress

McPoil, Hunt (1995) JOST Did not consider their theory original McPoil: while the tissue stress model is
by no means a novel idea
Meant to replace STJ neutral and Root

compensation theories for injuries
Tenets of Tissue Stress Theory

1. Accurately identify the anatomical structure which is injured or symptomatic. 2. Determine the structural and functional characteristics of the individual's foot and lower extremity.
3. Determine the most likely type of abnormal tissue stress which is causing the pathology within the injured anatomical structure (i.e. compression, tension or shearing stress). 4. Design a treatment protocol to reduce the abnormal tissue stresses on the injured structure and reduce the local inammatory response so that more normal gait and weightbearing function can occur.
Tissue Stress
Empirical observations Not an explanation Lets look deeper!
Conceptual Limitations and Impact of Theories
Humors
Bleeding, leeches & poultices Bleeding - is good for hemochromatosis Leeches are good for Dr. Armstrong but nano-worms are on the way Ptolomaic Copernican Galileo - house arrest Giordano Bruno - staked & burned by Cardinal Belarmine Pierre Teillard de Chardin
Geocentric vs. Heliocentric
Evolution v. 7000 year old world
Out of Many - One: Unied Theory
Cellular mechanics
Nature doesnt separate disciplines!
Mechanobiology Tensegrity Cell surface strain, activation of integrins Newton, Hook,Young Biomechanics Spring theory Pulsed forces Enzyme cascade Receptors (surface)
Physics
Biological systems theory
Other possibilities (to tissue stress)
Systems biology Genomics Cellular Mechanobiology and Energetics

(CME) (Cellular Mechanics)
Cells vs. Tissue
All tissues derive from cells, so it is at the cellular

level we are likely to nd our ultimate solutions. (Pribut 2009)
Lets Not Forget Wound Care

It isnt a magic soup you are pouring into
the wound
It isnt chefs special sauce There is more too it Cellular Mechanics plays a large role
Why look at the cell?
But which is the stone that supports the bridge? Kublai Khan asks. The bridge is not supported by one stone or another, Marco answers, but by the line of the arch they form. Why do you speak to me of stones? It is only the arch that matters to me. Polo answers: Without stones there is no arch. - Italo Calvino (Invisible Cities, 82)
The Cell: Basic Unit of Life
Cells > Tissues

The cell is to biology what the atom is to chemistry and physics. - after Niels Bohr with the cell, biology discovered its atom paraphrase of George Henry Lewes (1817-1878)
Cell Doctrine (1838,1839-1859)
All organisms are composed of one or

more cells
The cell is the basic unit of organization All cells come from preexisting ones
Virchow and others
Old Model of Cell Structure

Blob - like a balloon lled with uid Alteration in cell membrane shape via external forces
have little effect across entirety of cell
New Model of Cellular Structure

Tensegrity object Tensional integrity (Kenneth Snelson
creator/Buckminster Fuller applellation)
Microtubules (tubulin) Microlaments (actin) Tension in laments, compression in struts

Bendix image: Oxford
Tensegrity
Buckminster Fuller - named it Kenneth Snelson - made it Donald Ingber - nailed it brought it to a theory of the cell
The Needle
Built Like A Tent
(A) A high magnification view of a Snelson sculpture with sample compression and tension elements labeled to visualize the tensegrity force balance based on local compression and continuous tension.
Ingber D E J Cell Sci 2003;116:1157-1173
2003 by The Company of Biologists Ltd Friday, August 17, 12
He la cells Cytoskeleton
HeLa
Cellular & Molecular Mechanics

Mechanobiology Nanotechnology Chemical Biology Cellular biomechanics
Course Study NSF-GEM Summer School 2012

Introduction to Cell and Molecular Biology Introduction to Physiology Cell & Molecular Biomechanics: Basic Mechanics Introduction to Continuum, Fluid and Solid Mechanics Continuum & Statistical Mechanics Molecular Biomechanics Cell Biomechanics Tissue and Muscle Biomechanics Computational Biomechanics Mechanosensing and Transduction Musculoskeletal System Immune System Cellular/Subcellular Levels
Polymerizes into laments (crosslinks) Found in all eukaryote cells Interact with microtubules and
intermediate laments Polar - point in one direction First found with myosin in muscles
Spatial Cell Biology: Location, Location, Location
Vectors of reaction Field effect of gradients, reactions,movements, forces Interconnectivity and connectivity A place for everything and everything in the right place Directionality of transmembrane proteins Hox genes
56
Fig. 1 The genome as a GPS device.
H Y Chang Science 2009;326:1206-1207
Published by AAAS Friday, August 17, 12
New Cell Theory

Not only genes - but physics and chemistry Dynamic patterns generated by physical and biological systems can yield a eld effect Similarities to elds of force (electrical, magnetic, gravitational) Cell elds sustained by concentration gradient or patterns of dynamic mechanical stress and strain Field concept: creates discomfort among many biologists
The Way of The Cell, 2002
58
Cells as Adaptive Architecture: Intelligent Building Materials
Resilient and adequately strong Multifunctional optic, taste, touch, otic, neuro, mechanical Learn, adapt, self-organize Move, grow, recover from stresses Include self-organizing materials (protein
conformation, microtubules,)
After Ingber, 2011
ECM

More dynamic & versatile than previously thought Biomechanical properties range from soft and compliant to stiff and rigid Elasticity & biomechanical properties affect how a cell senses and detects external forces Focal adhesion complex (FAC) (integrins and signaling proteins) act as a mechanosensor links cytoskeleton with the ECM Change in mechanical force alters TGF-! signaling in mouse tendon (Maeda et al., 2011) indicating other signals may also be activated
ECM Components
Collagen & Elastic
Fibers
Glycoproteins Fluid
Cells in ECM
Produce and maintain extracellular matrix Fibroblasts: form bers Migratory: reactionary (immune response)
macrophages (red, orange) mast cells Lymphocytes
The extracellular matrix: A dynamic niche
February 20, 2012 // JCB vol. 196 no. 4 395-406 The Rockefeller University Press, doi: 10.1083/jcb.201102147 2012 Lu et al.
ECM Biomechanics
Major factor in cell fate determination Impact cell differentiation Affect cell and tissue function Matrix stiffening affects cell migration Dynamic and remodels - interacting with cells and
cell functions
Stem Cell Mechanobiology: ECM and the Stem Cell

Impact of matrix stiffness Hard - bone cell Soft - fat cell Medium - muscle cells Stiffness of ECM Youngs modulus Impacts genetic expression
65
Integrins
Transmembrane Cell attachment to other cells or ECM
(celll-cell / cell-ECM)
Stabilize cells and tissues Remodeling of focal adhesions affects cell

shape, gene expression and tissue organisation.
Conformational changes
Alter binding affinity Possibly force dependent Enzymes/Proteins linked to cytoskeleton Mechanics plays large
Integrins play a role in cell stiffness detection Alteration of conformation of cytoskeleton

Wang et al (2009)
Summary: Integrins
Connect in 2 directions: the ECM to the cytoskeleton and cell membrane to the nucleus Signal both outside-in and from the inside-out Detect forces in their environment Affects the movement of cells Functional changes: conformation and clustering Activate tyrosine kinases
Cell Mechanics
Challenges the central dogma which is
to researchers and clinicians followed by disease based researchers (biologists, physicians)(DNA-RNA-Protein)
Cell/molecular mechanics is a new concept Young and developing eld Georgia Tech, Emory, MIT, Harvard - Leaders
& Lecturers
Cells and uid shear stress

Almost all cells respond to uid shear stress
Kamkin A, Kiseleva I, editors. Mechanosensitivity in Cells and Tissues. Moscow: Academia; 2005. Appendix. Available from: http:// www.ncbi.nlm.nih.gov/books/NBK7500/
Most endothelial cells orient in direction of uid shear (except heart valve endothelial cells and vascular smooth muscle) Lower cells: dinoagellates (red tide) - produce phospholuminescence to mild uid shear Single cell grouping to form multicellular organisms - cell connectivity (surface receptors) response to shear
Molecular mechanisms for integration of mechanical/adhesive signals.
Weber G F et al. J Cell Sci 2011;124:1183-1193
2011 by The Company of Biologists Ltd Friday, August 17, 12
Mechanotransduction: Recent Theories

(after Roger D. Kamm of MIT)
Changes in membrane uidity and the diffusivity of
transmembrane receptors --> receptor clustering (Butler, 2002, Wang, 2004) and gene expression (Ingber)
Direct mechanical effects on the nuclear membrane, DNA, Stretch-activated ion channels (Gullinsgrud, 2003, 2004) Force-induced changes in the conformation of loadbearing proteins (Schwartz, 2001, Jiang, 2003, Bao, 2002)
Another -ome

Ominomics - spreading widely and not happily (WSJ Aug 15, 2012) One more: The Mechanome (M. Lang, MIT):
The complete state of stress existing from tissues to cells to molecules The biological state that results from the distribution of forces Knowledge of the mechanome requires:
the distribution of force throughout the cell/organ/body the functional interactions between these stresses and the fundamental biological processes
Mechanomics is then the study of how forces are transmitted and the inuence they have on biological function
Bone
Bone
Julius Wolff (1892)

First recognized ability of tissue to adapt to mechanical stresses Observed trabeculae matched the principal stress lines of bone How does a force become a cascade of biological signals? Wolffs law - old & simplied & narrow but not wrong Mechanotransduction - new & can be generalized
Osteocyte: The Mechanosensor

Dynamic uid ow with higher peak shear stress amplitudes, faster oscillating frequencies, and longer loading durations are optimal for promoting bone formation. Structural adaptation of the bone is mediated by loading-induced interstitial uid ow within the bone microstructure. Osteocytes are the central mechanotransducer and mechanosensor demonstrated that COX-2 mRNA levels are elevated in osteocytes subjected to higher peak shear stress and longer ow durations RANKL/OPG mRNA levels decreased in response to higher peak shear stress amplitudes, faster oscillating frequencies, and longer ow durations.
Biomechanics
Where does what we know t in? Does foot strike and running
mechanics play a role? to bone?
How do orthotics impact the signal What exactly is the signal and how
does the signaling work?
Gait Analysis Treadmill: Dream Machine
h/p/cosmos Quasar Treadmill

about $24,000 Friday, August 17, 12
Good Vibrations

Just the right amount helps Too much hurts Complex signal Alterations in running cadence, speed, shoe, terrain will alter the input into the musculoskeletal system Standing waves - augmented wave forms As Paul Langer mentioned: Barefoot: more variability in step rate, length. Possibly helpful for certain injuries.
Complex Functions: Body & Vibration

Shoe, Surface, Body - have an impact on vibration. In phase and out of phase qualities factor in. Benno Niggs - muscle tuning + bonus Bessel Functions - wavelike oscillatory behavior or a combination of oscillation & exponential decay or growth Fourier Transformation - potential lter via soft tissue.
Schematic diagram of how forces applied through the ECM (A) or directly to the cell surface (B) travel to integrinanchored focal adhesions through matrix attachments or cytoskeletal filaments, respectively
Published by AAAS
F. J. Alenghat et al., Sci. STKE 2002, pe6 (2002)
Relationship Status: Its Complicated
Schematic diagram of how forces applied through the ECM or directly to the cell surface travel to integrin-anchored focal adhesions through matrix attachments or cytoskeletal filaments
Cytokines are a part of the soup many of us are looking for.
Cytokines and Growth Factors Affecting Bone: Stimulators of Resorption
Cytokines and Growth Factors Affecting Bone: Inhibitors of Resorption
Cytokines and Growth Factors Affecting Bone: Stimulator of Formation
Look for something that inhibits destruction and enhances formation Then you may nd the MSG of cell making soup.
Mouse study Stimulates osteoblast differentiation Inhibits osteoclast activity (anti-osteoclastogenic) Osteoprotective Contrast with alendronate (only inhibits resorption)
Coupling bone synthesis and degradation.
SEM3a:
Translational medicine: Double protection for weakened bones

Mone Zaidi & Jameel Iqbal Nature 485, 4748 (03 May 2012) doi:10.1038/485047a
Osteoporosis
Primary
Type I - Post-menopausal (estrogen-induced)
trabecular bone loss > cortical
Type II - Age related

both trabecular and cortical bone loss
Secondary
pharmaceuticals, endocrine disorder, chronic renal disease, immobilization, nutritional, connective tissue disorders
91
Cortical Bone and Aging
Trabecular bone fairs worse With a decrease in BMD the cortex
becomes thinner making for higher fracture risk
Medication: Impact On Injury

Prilosec, Protonix - increase risk of fracture
and stress fracture
Fluoroquinones - increase risk of tendon

and ligament injury
NSAIDs - questionable connection

Nutrients, Aging and Bone

Decreased protein intake leads to sarcopenia Sarcopenia leads to decreased skeletal loading and decreased IGF-1 Decrease hormones Vitamin deciencies Bone Weakens
from Nutrition, Bone and Aging
Bone Healing Stimulators

Utility Cost Evolution
Principles and First Attempts in Stimulating Bone Healing
Pizeoelectric crystal theory Basset and Becker, Science 1962 Led to implantable electrodes Anode/Cathode - tissue destruction
Bone Stimulator: Ultrasound Based

Based on observation and thought that stress was
helpful
Actions appear to be based on mechanotransduction Cannalicular uid ow stimulates osteocytes (shear

forces)
30 minutes per day

Problems & Solutions in Bone Healing

Pricing - $3000 Distribution Company representatives eBay Disposable with built in obsolescence - number of
charges
US Stimulation of Bone Healing

Yes, it works Extremely useful delayed union Jones and other fth metatarsal base/shaft fractures
Tendon
Tendon: Function & Properties
Attach muscle to bone Remember: It is a musculoskeletal system Relatively avascular, slow metabolism
101
Tendon Loading
Transmits the force of contraction to bone High mechanical loads 4 times body weight (2600 N) during walking 8 times body weight (31005330 N) during running and jumping Adaptable
102
Seek Optimal Loading
et. al. 2004
theoretical framework of strain based ber reorientation
Does Tendon Hypertrophy With Use?
http://biodidac.bio.uottawa.ca/info/regles.htm
There was a signicant difference in CSA along the length of the tendon in both runners (P<0.001) and non-runners (P<0.01) (Fig. 2 (36% greater CSA at distal aspect, but not proximal)
6 male runners ~ 80 km/ week (5 years experience) Control: 6 non runners
10 male runners 10 female runners 10 female non-runners MRI/US examinations (Patellar & Achilles) Men CSA > Women Women trained = untrained
Distal patellar and Achilles tendon CSAs were greater than the proximal part in all three groups
Women seem to exhibit less adaptive response in tendon

Mechanism of Hypertrophy
Possibly increased cross linking between
collagen molecules or brils
Slow adaptation Men > Women Impact of estrogen? Methodology: US v. MRI

Body builder and ROH Wrestler Mike Mondo
What makes tendons pop?

Fluroquinolone: Increase real or illusion? Sex linked? Overload when not properly adapted? CSA & Genetics?
Between 1991 - 2002 risk increased from

22.1 to 32.6/100,000 (Denmark) Evaluated within 90 d of use Fluoroquinolone use -Tripled the risk Sex-standardized calculation
Long term exercise: improves mechanical properties Immobilisation - weakens mechanical structure Applied strain affects synthesis of matrix proteins Set point: Too low or too high = catabolism Just right = stimulation for optimal remodeling
16 men Plantar exion isometric resistance training Tendon stiffness increases over 2 - 3 month period Adapts to resistance training slowly, but to detraining
rapidly. Less vigorous than Alfredson protocol LOWER VOLUME: Less Pain = More Gain
Achilles Tendinopathy
Eccentric Stretching (indiscriminately applied) PRP Surgery
115
Achilles Tendinopathy
Poultices and Plasters Leeches Bleeding
116
Little evidence in its favor Researchers need to determine the optimal

protocol for preparation and injection
Is PRP like Chefs Special Sauce

How can we get the right stuff? Should we throw a blender and a
centrifuge at the problem?
Biologist Analysis of Circuit Board
all followed at 6, 12, 24 weeks eccentric stretching + saline or PRP no signicant difference between control
and study group
Short & Intermediate term: No Difference

Am J Sports Med 2011 39: 1623 (online May 21, 2011)
59.3% (16 patients of 54 randomized) were satised with treatment

(insignicant difference of -2.7% in treated group) 56.5% returned to previous sports level (difference +1.8%) 1 Year Follow UP: No benet of PRP over placebo
Conclusion: A PRP injection in addition to eccentric exercises did not result in clinical improvement or improved structural reorganization after 1 year in chronic mid-portion Achilles tendinopathy compared with a placebo.
Plane of Progression
Tendinopathy
Achilles Posterior tibial (+ deltoid ligament) Peroneus longus or peroneus brevis Flexor hallucis longus
FHL Tendinopathy
Causes Dorsiexion exercises for plantar fasciitis Lack of exion stability in shoe Flip-op or open heel shoe
FHL Tendinopathy: Treatment

Stop offending exercises Toss bad shoes Strengthening exercises Use stability shoes Orthotic to reduce load on tendon
Mechanobiology: What Else Can Be Done?

Nano-delivery of drugs Biological nano-robotics Nano-worms/leeches
Synthetic Platelets
Model for improved handling of clot in tendon healing? Who you gonna call? Clot Busters!
UC Santa Barbara, via Science Daily 2012
Liquid Plumr for capillaries

Nanoparticles Biodegradable Deliver low dose tPA New method of drug
delivery Could help in diagnosis of location by scanning Designed to break apart at specic shear level
nanoparticles release tPA - shear force trigger (Ingber, 2012) (Wyss Institute of Harvard)
Casts
Plaster Polymer resin Cam Walkers / Pneumatic Cast Boot
Plaster

Gypsum (Calcium sulfate) Gives off heat when mixed with water forming a dihydrate: 2CaSO4.!H2O(s) + 3H2O(l)" = 2CaSO4.2H2O(s) Easily decorated Not stable when wet. Not very strong Smells, skin irritation, muscle atrophy, itchy, panic attacks
Heather Tomkins, anatomical drawing on a plaster cast. via boingboing
Plastic Resin Polymers

Fiberglass - reinforced
polymers for improved strength resistant
Lighter, stronger, water Decorator colors Similar problems to Plaster

re: hygiene
Pneumatic Walking Cast

Previous materials Plaster Plastic polymer resin
(berglass)
Solved - much of Cast

Disease
Allows exercise
Pneumatic Cast Boot: Problems

Occlusive Over-inated too often Skin rashes - allergy to materials, bers Nerve damage from compression Affects balance Limb length related problems - back, other joints axis alignment not correct: other pains
Fixing The Boot

Breathable material Feedback system to prevent over-ination Material testing to avoid ber shards. (Breathability improvement less moisture and leaching of materials from lining) Limb length equalizers to be dispensed with boot Find a better way to align with ankle axis Production facility - stability, compliance with standards
Answers to 4 Questions

Does eccentric stretching work? Why didnt PRP work better than saline for Achilles tendinopathy? How does ultrasound stimulate bone healing? Does mechanics play a role in healing?
Sometimes Eccentric stretching Mechanics and uid shear Yes, indeed
After Lecture:
Ingber: View of Modern Biomechanics

we still have no conceptual framework that
embraces basic paradigms of biology together with physical principles such as conservation of mass, momentum and energy prediction of the many shapes, material properties, motions, and uxes that are encountered in the living world
Fredberg, Discher, Ingber et. al.. Biomechanics: cell research and applications for the next decade. Ann Biomed Eng. 2009 May, 37(5) 847-859
we lack a comprehensive theory that permits
New Rules for Orthotics

! ! ! !
Problem specic planning Conform well or appropriately to the foot Be made over a 3D image or model of the foot Alter the application of forces as determined to be appropriate for the clinical problem. Be based on an examination of both the static and dynamic biomechanics, kinetics and kinematics (as much as is possible.) Take into account the requirements of the individual, sport, environment, and foot wear.
Cell Rules
Mechanotransduction Unit - Cell + ECM Reset cellular activity by alteration of biomechanical forces Impact via

Mechanics Diet Genetics Hormonal considerations Cell signaling biochemistry
142
Mechanics and Mechanotransduction
Encyclopedia of Biomaterials and Biomedical Engineering, 2008, p.1783-1793, Taylor & Francis)

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Overuse Bone & Tendon Injury Theories of Tomorrow

Stephen M. Pribut, D.P.M., FAAPSM, FACFAS Past President, AAPSM

Friday, August 17, 12

Friday, August 17, 12

Friday, August 17, 12

Friday, August 17, 12

Where We Are Going

Introduction Old Theories and New (tissue theory) Bone Tendons

15% 10% 25% 10%

Cell Mechanics and Mechanotransduction 40%

And now for something completely different...

Friday, August 17, 12

Dive Deep & Think Hard

Structure creates function Mechanics or enzyme cascade or both?

Friday, August 17, 12

More thinkers, theorists and researchers are needed!

Friday, August 17, 12

How and from where do scientists get ideas?

Friday, August 17, 12

Friday, August 17, 12

Murray Gell-Mann chose name in Admitted to perusing the

Feels beauty and elegance plays

Friday, August 17, 12

than others, it is because I have stood on the shoulders of giants.

Special relativity built on the work of Maxwell

Friday, August 17, 12

One View: You didnt build that alone.

Friday, August 17, 12

The joke was not approved by Einstein.

Break Down the Barriers

Friday, August 17, 12

Bone & Tendon Maintenance and Healing

Exercise Aging Sleep

Diet Genetics Psychiatric Disorders (some evidence)

Friday, August 17, 12

Mind & Gait

Friday, August 17, 12

Gait Revealer of Aging & Alzheimer's

Mayo Clinic: N= 1341, followed over 15 months

Basel, Switzerland: N= 1153, mean age of 78

Mind & Bone

Friday, August 17, 12

Depression & Bone Risk

Possible Factors Involved in BMD and Depression

Exercise, Mind & Bone

Friday, August 17, 12

Will we kiss tissue stress theory goodbye?

Friday, August 17, 12

What should we look at?

Levels Of Concern: Getting Small

Friday, August 17, 12

Friday, August 17, 12

Thinking Too Narrow

lower extremityspecic theories

Friday, August 17, 12

Less narrow: Tissue Stress

Meant to replace STJ neutral and Root

Tenets of Tissue Stress Theory

Friday, August 17, 12

Friday, August 17, 12

Conceptual Limitations and Impact of Theories

Geocentric vs. Heliocentric

Friday, August 17, 12

Evolution v. 7000 year old world