2020 J. Leonard Goldner Award Winner: Inhibition of HMGB1 by Metformin Prevents Mechanical Overloading-Induced Tendinopathy

Category: Basic Sciences/Biologics; Sports Introduction/Purpose: Tendinopathy is a debilitating tendon disorder that affects millions of Americans and costs billions of healthcare dollars every year. Mechanical overloading is considered to cause the development of tendinopathy, but the underlying molecular mechanisms of tendinopathy remain unclear. High mobility group box-1 (HMGB1), an upstream potent inflammatory mediator, has been identified in high levels in early stage tendinopathy patients [1]. However, whether HMGB1 mediates tendinopathy development due to mechanical overloading is completely unknown. Metformin (Met), a hypoglycemic drug commonly used for the treatment of type II diabetes, has shown to inhibit the activity of HMGB1 via binding the acidic tail of HMGB1 [2]. In this study, we tested the hypothesis that Met prevents mechanical overloading-induced tendinopathy by inhibiting HMGB1. Methods: A total of 24 mice were divided into 4 groups and treated for 24 weeks as follows: Group 1 (Cage) with cage activities; Group 2 (Met) received daily IP injection of metformin (50 mg/kg body weight); Group 3 (ITR) ran on treadmill at 15 meters/min for 3 h/ day, 5 days a week; Group 4 (ITR+Met) ran the same protocol as that of ITR group but with daily IP injection of metformin. Six mice/group were sacrificed at 24 weeks and the Achilles and patellar tendon tissues were harvested. The tendons from the left legs were used for histochemical staining and the right for immunostaining. Results: We found that mechanical overloading induced HMGB1 release into tendon matrix (Fig. 1G, K, O). Metformin inhibited HMGB1 release (Fig. 1H, L, P). ITR induced degenerative tendinopathy as evidenced by the cell morphological changes from elongated shape in normal tendon (Fig. 2A, E, I, M) to round shape (Fig. 2C, G, K, O) and the accumulation of proteoglycans (Fig. 2K, O) in ITR tendon. Metformin injection inhibited ITR effect, which is shown by less round shaped cells and low proteoglycan levels found in metformin injected ITR tendons (Fig. 2D, H, L, P). ITR promoted the expression of chondrogenic markers (collagen II and SOX-9) in tendon (Fig. 3C, G, K, O), and metformin inhibited the expression of chondrogenic makers (Fig. 3D, H, L, P). Conclusion: Our study demonstrated that mechanical overloading induced degenerative changes in mouse tendons characterized by the presence of chondrocyte-like cells, accumulation of proteoglycans, high levels of chondrogenic marker SOX-9 and Collagen II expression. Administration of metformint reduced the degenerative responses in overloaded tendon and blocked the development of tendinopathy. These findings support the notion that mechanical overloading induces tendinopathy development by initiation of tendon inflammation via HMGB1, which leads to eventual tendon degeneration. Thus, metformin, a commonly prescribed and FDA approved drug that specifically inhibits HMGB1, can be used to prevent tendinopathy development due to mechanical overloading placed on the tendon.