Article Text

Download PDFPDF

Original article
Targeting danger molecules in tendinopathy: the HMGB1/TLR4 axis
  1. Moeed Akbar1,
  2. Derek S Gilchrist1,
  3. Susan M Kitson1,
  4. Briana Nelis1,
  5. Lindsay A N Crowe1,
  6. Emma Garcia-Melchor1,
  7. James H Reilly1,
  8. Shauna C Kerr1,
  9. George A C Murrell2,
  10. Iain B McInnes1 and
  11. Neal L Millar1
  1. 1 Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland, UK
  2. 2 Department of Orthopaedic Surgery, Orthopaedic Research Institute, St George Hospital Campus, University of New South Wales, Sydney, New South Wales, Australia
  1. Correspondence to Mr Neal L Millar; neal.millar{at}


Objectives To seek evidence of the danger molecule, high-mobility group protein B1 (HMGB1) expression in human tendinopathy and thereafter, to explore mechanisms where HMGB1 may regulate inflammatory mediators and matrix regulation in human tendinopathy.

Methods Torn supraspinatus tendon (established pathology) and matched intact subscapularis tendon (representing ‘early pathology’) biopsies were collected from patients undergoing arthroscopic shoulder surgery. Control samples of subscapularis tendon were collected from patients undergoing arthroscopic stabilisation surgery. Markers of inflammation and HMGB1 were quantified by reverse transcriptase PCR (RT-PCR) and immunohistochemistry. Human tendon-derived primary cells were derived from hamstring tendon tissue obtained during hamstring tendon anterior cruciate ligament reconstruction and used through passage 3. In vitro effects of recombinant HMGB1 on tenocyte matrix and inflammatory potential were measured using quantitative RT-PCR, ELISA and immunohistochemistry staining.

Results Tendinopathic tissues demonstrated significantly increased levels of the danger molecule HMGB1 compared with control tissues with early tendinopathy tissue showing the greatest expression. The addition of recombinant human HMGB1 to tenocytes led to significant increase in expression of a number of inflammatory mediators, including interleukin 1 beta (IL-1β), IL-6, IL-33, CCL2 and CXCL12, in vitro. Further analysis demonstrated rhHMGB1 treatment resulted in increased expression of genes involved in matrix remodelling. Significant increases were observed in Col3, Tenascin-C and Decorin. Moreover, blocking HMGB1 signalling via toll-like receptor 4 (TLR4) silencing reversed these key inflammatory and matrix changes.

Conclusion HMGB1 is present in human tendinopathy and can regulate inflammatory cytokines and matrix changes. We propose HMGB1 as a mediator driving the inflammatory/matrix crosstalk and manipulation of the HMGB1/TLR4 axis may offer novel therapeutic approaches targeting inflammatory mechanisms in the management of human tendon disorders.

  • inflammation
  • tendinopathy
  • cytokines
  • HMGB1
  • TLR4
  • translational

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

View Full Text

Statistics from


  • Contributors NLM, MA and DSG conceived and designed the experiments. NLM, MA, JHR, SCK, LANC and BN performed experiments. GACM and IBM provided expert advice. All authors analysed the data. NLM wrote the paper.

  • Funding This work was funded by grants from the Wellcome Trust (WT100651MA) and Arthritis Research UK (21346).

  • Competing interests None declared.

  • Ethics approval West of Scotland REC and South East Sydney Area Health Service REC.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement MA and NLM have access to all the data and data are available upon request.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.