How diet, Type II diabetes and obesity compromise tendon healing

Marion Hauser, MS, RD

In this article we will examine the research surrounding the problems of a broken tendon healing cycle caused by problems of diabetes and obesity.

If you are having concerns about your diabetes and obesity hindering your healing ability,you can get help and information from our Caring Medical staff.

In the medical publication Nutrition, researcher Luke Curtis wrote that tendon injures cause a great deal of disability and pain, and increase medical costs. However, relatively little is known about tendon biology and healing.

  • Many tendon-related surgical procedures are not very successful and leave the patient with essentially a chronic injury.
  • Preliminary evidence suggests that various nutrients such as proteins, amino acids (leucine, arginine, glutamine), vitamins C and D, manganese, copper, zinc, and phytochemicals may be useful in improving tendon growth and healing.

More research on nutrition and tendon health is needed. Because many nutrients are required for tendon health, nutritional interventions involving multiple nutrients may be more effective than single-nutrient strategies.(1)

The problem of tendon healing and nutrition has recently become a favorite subject to researchers. As Dr. Curtis points out there had been a lack of knowledge as to how the management of diabetes Type 2 and obesity affect tendon healing. This is changing.

In a July 2017 study from the University of Rochester Medical Center, Rochester, New York and the Mayo Clinic wrote in the online scientific journal PLos One (Public Library of Science one) that:

  • Type II Diabetes dramatically impairs the tendon’s ability to heal resulting in decreased collagen organization and mechanics relative to non-diabetic tendons.
    • In other words Type II Diabetes prevents the full production of the collagen building blocks that are needed for any soft tissue healing.
  • Despite this problem, there is little research or information regarding the mechanisms that govern impaired healing of diabetic tendons.

To bring light to this problem, the researchers placed mice  on either a high fat diet or low fat diet and underwent flexor tendon transection and repair surgery to simulate tendon injury and repair.

  • Healing was assessed via mechanical testing, histology and changes in gene expression associated with collagen synthesis, matrix remodeling, and macrophage polarization.
    • What the researchers were looking for was “gene expression associated with collagen synthesis.” The communication between genes that begin the repair process by creating collagen.
    • “Matrix remodeling.” This is a fascinating subject on how the extracellular matrix directs healing damaged areas. The matrix is the “bricks and mortar” of wound repair, we cover this at length in our article Extracellular matrix in osteoarthritis and joint healing.
    • “Macrophage polarization.” Macrophages clean up injury debris or dead or dying tissue. When there is increased macrophage infiltration, immune cells are invading the areas causing swelling and edema. For more on this subject as it relates to healing and nutrition, see our article Metabolic syndrome and osteoarthritis joint pain.

The findings?

  • Obese/diabetic tendons healed with increased scar formation and impaired mechanical properties.
  • Consistent with this, prolonged and excess expression of extracellular matrix (ECM) components were observed in obese/and type II Diabetes tendons.
    • What does this mean? Simply Macrophages are designated as MI (These are macrophages that work on infection, virus, and immune response to illness and M2 Macrophages.
    • M2 Macrophages are more designed for wound healing and chronic joint pain. Notice above when I said: “When there is increased macrophage infiltration, immune cells are invading the areas causing swelling and edema.” In chronic joint pain, this mechanism does not shut off leading to the problems of chronic inflammation. Please see our article How stem cells help fix a broken healing cycle, as chronic inflammation is a broken healing cycle.
  • As Macrophages are involved in both inflammatory and matrix deposition processes during healing. Obese/T2DM tendons healed with increased expression of markers of pro-inflammatory M1 macrophages, and elevated and prolonged expression of M2 macrophages markers that are involved in ECM deposition.
    • What does this mean? The researchers point out: “tendons from obese/diabetic mice heal with increased scar formation and increased M2 polarization (too much broken inflammation), identifying excess M2 macrophage activity and matrix synthesis as a potential mechanism of the fibrotic healing phenotype observed in type II Diabetes tendons tendons, and as such a potential target to improve tendon healing in type II Diabetes tendons.”(2)
    • In other words – Fix the broken healing cycle in this case by management of obesity and Type II diabetes! 

Our bodies are very clever when it comes to solving the problems of poor tendon healing in regard to diabetes. In a fascinating new study from a combined research team in the United Kingdom, Belgium and the United States (the University of Miami) doctors wrote in the medical journal Gait Posture of how diabetes patients walk differently than non-diabetic patients and it has something to do with tendons.

What the researchers were looking at was why diabetic patients expended more energy in walking than non-diabetic patients. This would obviously be an appealing subject for the easily fatigued diabetic patient.

  • The doctors looked at 31 non-diabetic control patients
  • 22 diabetes patients without peripheral neuropathy (weakness and pain from diabetic nerve damage)
  • and 14 patients with moderate/severe diabetic peripheral neuropathy

What the doctors found was not the answer as to why diabetic patients used more energy in walking than non-diabetic patients, but something really incredible. Patients with diabetes and mild diabetic peripheral neuropathy, unknowingly reduced ankle movement during walking to provide stability. How? By redirecting energy towards the ankle.

  • The body has put the ankle in a reduced motion mode to protect against injury from instability not only in the ankle but the achilles tendon as well. It did so in part by asking the the plantar flexor muscles to generate less power in walking.
  • The body recognized how Type II diabetes and obesity compromised healing and tried to prevent injury

If you are having concerns about your diabetes and obesity hindering your healing ability,you can get help and information from our Caring Medical staff.

1 Curtis L. Nutritional research may be useful in treating tendon injuries. Nutrition. 2016 Jun 30;32(6):617-9. [Google Scholar]

2 Ackerman JE, Geary MB, Orner CA, Bawany F, Loiselle A. Obesity/Type II Diabetes Alters Macrophage Polarization Resulting in a Fibrotic Tendon Healing Response. bioRxiv. 2017 Jan 1:131607.

3 Petrovic M, Deschamps K, Verschueren SM, Bowling FL, Maganaris CN, Boulton AJ, Reeves ND. Altered leverage around the ankle in people with diabetes: A natural strategy to modify the muscular contribution during walking? Gait & posture. 2017 May 19;57:85. [Google Scholar]

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