Ferroptosis in musculoskeletal disorders: Emerging mechanisms and therapeutic opportunities (Review)

Introduction of ferroptosis

Musculoskeletal disorders, including tendinopathy, sarcopenia, osteoarthritis and osteoporosis, represent a major and growing global health burden, with osteoarthritis affecting 32.5 million adults in the United States, osteoporosis affecting 8.4-17.7% of middle-aged and elderly adults and nearly half of skeletal muscle mass being lost by the age of 80 years due to sarcopenia (1,2), particularly in aging populations (3). These conditions are characterized by progressive tissue degeneration, impaired regenerative capacity and limited therapeutic options capable of restoring structural and functional integrity. Despite advances in understanding inflammatory signaling and mechanical stress-related injury, several aspects of musculoskeletal degeneration remain insufficiently explained at the level of regulated cell death and metabolic vulnerability (4,5). This gap suggests that additional mechanisms may underlie the progressive loss of tissue homeostasis observed in these disorders. Previous studies have identified ferroptosis, an iron-dependent form of regulated cell death driven by lipid peroxidation, as a potential contributor to tissue degeneration in multiple organ systems (6,7). Increasing evidence indicates that ferroptosis may intersect with iron dysregulation, oxidative stress and aging-associated metabolic alterations, features that are highly relevant to musculoskeletal tissues (8-11). These findings raise the possibility that ferroptosis represents a previously underappreciated mechanism in musculoskeletal decline (Fig. 1).

Figure 1 Graphical abstract illustrating the role of ferroptosis in musculoskeletal disorders. The diagram summarizes the core mechanisms of ferroptosis, including iron metabolism dysregulation, lipid peroxidation and impairment of antioxidant defense systems such as GPX4. These processes contribute to tissue degeneration across skeletal muscle, tendon, cartilage, intervertebral disc and bone. GSH, glutathione; GPX4, glutathione peroxidase 4; MDA, malondialdehyde.

Ferroptosis, first identified in 2012 (7), is a regulated form of iron-dependent cell death characterized by excessive lipid peroxidation and failure of antioxidant defense systems. It is driven by intracellular iron accumulation, depletion of glutathione (GSH), inactivation of GSH peroxidase 4 (GPX4) and subsequent oxidative damage to membrane phospholipids (11-14). Unlike necrosis or apoptosis, ferroptosis is associated with cellular metabolic state and redox homeostasis, forming a self-amplifying cycle among iron overload, reactive oxygen species (ROS) generation and lipid peroxidation (12,15). At the molecular level, dysregulation of iron-handling proteins, including transferrin receptor (TFRC), ferritin and ferroportin, contributes to free iron accumulation and promotes Fenton chemistry-mediated ROS production (16-23). Lipid peroxidation of polyunsaturated fatty acids, particularly in cellular membranes, represents a hallmark event of ferroptosis, while GPX4 and the system the cystine/glutamate antiporter (Xc−/) GSH axis serve as central antioxidant defenses that counteract this process (24-28). Mitochondrial dysfunction and oxidative stress further amplify ferroptotic signaling, as altered membrane potential, ROS overproduction and ferritinophagy-mediated iron release accelerate lipid damage and cell death (Fig. 2) (29-33).

Figure 2 Schematic illustration of ferritin-mediated regulation of iron homeostasis in ferroptosis. Ferritin maintains intracellular iron balance by storing excess iron in a non-toxic form. Disruption of ferritin turnover, particularly via ferritinophagy, leads to increased release of labile iron, enhanced Fenton reaction-mediated reactive oxygen species production and subsequent lipid peroxidation, thereby facilitating ferroptotic cell death. TFR1, transferrin receptor 1; FPN, ferroportin; FTL, ferritin light chain; FTH, ferritin heavy chain.

Musculoskeletal tissues possess unique metabolic and structural characteristics that may render them particularly susceptible to ferroptotic injury (4). Tendons and cartilage are relatively avascular and rely heavily on tightly regulated redox balance, while skeletal muscle exhibits high metabolic demand and mitochondrial activity (34). Moreover, aging-associated alterations in iron homeostasis, stem cell function and antioxidant capacity may further amplify ferroptotic vulnerability across these tissues (34). These features suggest that ferroptosis could represent a convergent mechanism underlying degeneration and impaired regeneration in the musculoskeletal system.

The present review aims to provide a comprehensive and disease-oriented synthesis of current evidence regarding ferroptosis in musculoskeletal disorders. The fundamental molecular mechanisms of ferroptosis is first summarized followed by examination of its involvement in major musculoskeletal conditions, including tendinopathy, sarcopenia, osteoarthritis and osteoporosis. The present review further discuss aging-related modulation, experimental modeling strategies and emerging therapeutic perspectives to clarify the potential translational significance of targeting ferroptosis in musculoskeletal disease.

Application of ferroptosis in the musculoskeletal system

Musculoskeletal tissues exhibit distinct metabolic and structural characteristics that may influence their susceptibility to ferroptotic injury. Skeletal muscle is highly metabolically active and relies on robust mitochondrial function to sustain contractile activity. This high oxidative demand renders muscle fibers and muscle stem cells particularly sensitive to redox imbalance and iron-mediated lipid peroxidation (35-38). Notably, activation of ferroptosis in muscle stem cells has been shown to impair regenerative capacity by disrupting intracellular iron homeostasis and antioxidant defenses, leading to excessive lipid peroxidation and mitochondrial dysfunction. These alterations compromise satellite cell viability and functional maintenance, thereby contributing to accelerated muscle aging (39). Tendons, by contrast, are relatively avascular connective tissues with limited intrinsic antioxidant capacity (40,41). Their restricted blood supply may compromise redox buffering under stress conditions, potentially increasing vulnerability to iron accumulation and lipid peroxidation. Aging-associated dysfunction of tendon-derived stem cells further contributes to impaired repair, and emerging research suggests that ferroptosis may participate in this degenerative process (9,42,43). However, the interaction between cellular senescence, iron metabolism and ferroptosis remains complex and may vary depending on ferritinophagy status and intracellular iron handling (44). Bone tissue undergoes continuous remodeling through tightly regulated interactions between osteoblasts, osteoclasts and osteocytes (45). This dynamic process involves substantial metabolic activity and iron flux. A recent study have identified ferroptosis as a potential mechanism contributing to osteocyte loss and cortical bone degeneration during aging (46). Collectively, these tissue-specific characteristics suggest that ferroptosis may represent a convergent mechanism associating metabolic stress, iron dysregulation and impaired regeneration across the musculoskeletal system.

To provide a comparative overview of ferroptosis involvement across musculoskeletal tissues and diseases, the present review systematically summarizes key ferroptosis-related biomarkers reported in tendinopathy, muscle degeneration, sarcopenia, osteoporosis and other degenerative conditions, highlighting shared molecular signatures and conserved regulatory pathways (Table I).

Table I Important biomarker of ferroptosis in musculoskeletal system related diseases.

Table I

Important biomarker of ferroptosis in musculoskeletal system related diseases.

Diseases	Biomarkers	(Refs.)
Tendinopathy	GPX4, SLC7A11, FSP1	(49)
Tendinopathy	ACSL4, GPX4, TfR1	(42)
Tendinopathy	GPX4, SLC7A11	(43)
Aged tendon	GPX4, ACSL4	(9)
Aged skeletal muscle	TfR1, SLC39A14, GPX4, FTH	(39)
Sarcopenia	SLC7A11, GPX4	(57)
Muscle wasting	ACSL4, GPX4	(57)
Muscle aging	FTH, GPX4, SLC7A11, FTL	(56)
Muscle aging	ACSL4, GPX4	(61)
Osteoporosis	GPX4, ACSL4	(101)
Osteoporosis	TFR1, FPN, GPX4, SLC7A11	(120)
Postmenopausal osteoporosis	GPX4, SLC7A11	(102)
Intervertebral disc degeneration	ACSL4, GPX4, FTH	(115,123)
Intervertebral disc degeneration	ACSL4, GPX4	(113)
Osteoarthritis	FTH, GPX4	(122)

[i] ACSL4, acyl-CoA synthetase long-chain family member 4; FPN1, ferroportin 1; GPX4, glutathione peroxidase 4; TfR1, transferrin receptor protein 1; FTH, ferritin heavy polypeptide 1; FTL, ferritin light polypeptide; SLC7A11, solute carrier family 7 member 11.

The occurrence of ferroptosis in tendinopathy

Tendinopathy is commonly defined as unexplained tendon pain and may be associated with tears, inflammatory entheses or chronic degenerative lesions. It is a prevalent sports injury, with varying incidence rates across athletic populations: The rate of achilles tendon rupture reaches 52% in former elite runners, 24% in competitive athletes and 18% in athletes under 45 years of age; patellar tendinopathy affects 45% of volleyball players and 32% of basketball players (47), and chronic tendinopathy is often observed alongside more severe conditions, such as tendon damage or rupture (48), although causal relationships remain to be fully established. In 2022, a study suggested a potential association between ferroptosis and tendinopathy. In particular, Wu et al (49) reported that treatment with Farrerol (FA) was associated with a reduction in collagenase-induced tendinopathy, potentially involving modulation of ferroptosis. The study observed that tendinopathy is associated with iron accumulation in tendon cells and that FA treatment coincided with reduced lipid peroxidation, increased GSH levels and decreased iron accumulation, consistent with reduced ferroptosis. However, the study also observed that FA treatment was associated with reduced inflammatory cell response and infiltration (49), suggesting a potential association between ferroptosis and inflammation. Differential gene expression analysis from RNA sequencing of rotator cuff injury samples treated with the anti-inflammatory agents celecoxib and lactoferrin showed an association with ferroptosis (50). Subsequent analysis of differential genes in rotator cuff injury identified key ferroptosis-related genes, such as Acsl3, Cybb, Ascl4, Flt3, and Sat1 and further confirmed that ferroptosis is indeed interconnected with inflammation in rotator cuff tears. This finding indicated a possible association between ferroptosis inhibition and reduced inflammatory markers (51), though causality remains to be determined. Ferroptosis is also frequently associated with metabolic diseases, with diabetes being a typical example. A Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis of differential genes in rotator cuff tear samples from diabetic and non-diabetic patients revealed an association with the ferroptosis signaling pathway (52). In a study on the db/db mouse model of diabetes, changes in the cellular microenvironment were found to make the mice more prone to tendinopathy, which was associated with ferroptosis (42). In the study by Wang et al (42), YAP, a key transcription factor in the Hippo signaling pathway known to be involved in various types of cancer (53), was found to associate with ACSL4 expression. Both YAP and ACSL4 levels were elevated in the diabetic microenvironment, coinciding with increased markers of ferroptosis, suggesting a potential regulatory association between YAP, ACSL4 and ferroptosis. The study observed that ferroptosis inhibitors were associated with reduced signs of diabetes-induced tendinopathy (42). The occurrence of tendinopathy is accompanied by the aging of tendon stem cells, which is triggered by oxidative stress. Gao et al (43) reported that hydrogen peroxide-induced oxidative stress in tendon stem cells activates the cGAS-STING signaling pathway in parallel with mitochondrial damage, mitophagy dysregulation and ferroptosis-related molecular alterations, ultimately contributing to tendinopathy-associated pathological phenotypes. Mechanistically, these findings support the cGAS-STING pathway as a stress-responsive damage-sensing signaling axis activated under oxidative stress conditions, rather than as a primary upstream driver of ferroptosis initiation. Within this framework, cGAS-STING is more appropriately positioned as a downstream modulatory and signal-amplifying node within the oxidative stress-mitochondrial dysfunction-ferroptosis regulatory network in tendon stem cells. Its activation may enhance inflammatory signaling and ferroptosis susceptibility through feedback regulation and pathway cross-talk, thereby contributing to degenerative progression. Further studies are warranted to clarify its hierarchical positioning and regulatory interactions in tendon degeneration. Another study on tendon stem cell aging and ferroptosis found that ferroptosis could promote tendon stem cell aging, leading to tendon degeneration and aging, while also affecting tendon-bone healing and mechanical strength (9). Therefore, tendon stem cell aging may be triggered by ferroptosis, which occurs concurrently with tendinopathy. Additionally, a bioinformatics analysis of sequencing data from patients with frozen shoulder revealed an association with ferroptosis. Ferroptosis influences the pathological processes of frozen shoulder and Il-6, Hmox1 and Tlr4 genes have been identified as potential therapeutic targets for this condition (54), as supported by transcriptomic and computational analyses conducted using established bioinformatics frameworks.

Current research associating ferroptosis to tendon stem cell aging and impaired regeneration is primarily derived from indirect indicators, including alterations in molecular expression profiles, increased oxidative stress levels, dysregulated iron metabolism and activation of ferroptosis-related signaling pathways. These findings mainly support associations and mechanistic inferences, while direct causal validation at the level of cell lineage and fate determination remains lacking. Future studies integrating lineage tracing models, single-cell transcriptomic analyses and spatial mapping of ferroptosis-specific markers in human tendon tissues will be essential to systematically validate the causal role of ferroptosis in tendon stem cell aging and regenerative decline. Such approaches will enable mechanistic dissection at the levels of cell fate determination, cellular subpopulation heterogeneity and tissue microenvironmental regulation, thereby establishing a more mechanistically robust and translationally relevant theoretical framework. Collectively, these studies indicate that ferroptosis is deeply integrated into the pathophysiological processes of tendinopathy through coordinated interactions among oxidative stress, inflammatory signaling, metabolic dysregulation and tendon stem cell aging (9,42,49). These interconnected mechanisms converge on iron accumulation, lipid peroxidation and membrane damage, ultimately driving ferroptotic cell death and tendon degeneration. the present review integrates these multi-axis regulatory pathways into a unified mechanistic framework, illustrating how mitochondrial damage-associated inflammatory signaling, mechanical stress-induced oxidative injury and metabolic reprogramming-driven lipid peroxidation collectively contribute to ferroptosis in tendon pathology (Fig. 3).

Figure 3 Ferroptosis in tendon-related diseases. Mitochondrial damage activates the cGAS-STING pathway, leading to iron accumulation and inflammatory responses. Mechanical stress induces ROS production and lipid peroxidation, resulting in membrane damage. In addition, hyperglycemia activates the YAP-ACSL4 axis, enhancing PUFA-dependent lipid ROS generation. These pathways collectively promote ferroptotic cell death and contribute to tendon degeneration. GM-CSF, granulocyte-macrophage colony-stimulating factor; LPS, lipopolysaccharide; YAP, Yes-associated protein 1; ACSL4, acyl-CoA synthetase long-chain family member 4; PUFA, polyunsaturated fatty acid.

The occurrence of ferroptosis in muscle-related diseases

Iron metabolism plays a key role in muscle diseases, and the occurrence of ferroptosis can lead to muscle-related disorders (55-58). It is possible that ferroptosis not only promotes muscle aging but also contributes to muscle atrophy. Sarcopenia, which is a clinical manifestation of this process, can further lead to muscle wasting, and both conditions are associated with the occurrence of ferroptosis (Fig. 4).

Figure 4 Role of ferroptosis in muscle-related diseases. The diagram summarizes key mechanisms involved in skeletal muscle aging, sarcopenia and muscle atrophy, including iron dysregulation, mitochondrial dysfunction and impaired antioxidant defense. Ferroptosis contributes to reduced muscle regeneration, stem cell dysfunction and loss of muscle mass and function. KEAP1, Kelch-like ECH-associated protein 1; NRF2, nuclear factor erythroid 2-related factor 2; GPX4, glutathione peroxidase 4; TFR, transferrin receptor; MSTN, myostatin; SLC7A11, solute carrier family 7 member 11; p53, tumor protein p53; p16, cyclin-dependent kinase inhibitor 2A; p21, cyclin-dependent kinase inhibitor 1A.

Skeletal muscle aging

Skeletal muscle aging is a physiological phenomenon that is often accompanied by the onset of sarcopenia and other related diseases such as osteoporosis and osteoarthritis (59). Different subtypes of muscle stem cells contribute to distinct aging phenotypes (60). Compared with young mice, aged mice exhibit markedly reduced expression of GPX4 in skeletal muscle. Moreover, defects in cystathionine γ-lyase (CSE) exacerbate GPX4 reduction, thereby inducing ferroptosis in skeletal muscle (61). As aging progresses, the expression of TFRC declines in both skeletal muscle and satellite cells. The loss of TFRC triggers ferroptosis, impairing skeletal muscle regeneration (39). In a study utilizing Tfr1-specific knockout mice, Tfr1 depletion resulted in an ~60% irreversible reduction in satellite cell population, along with defects in proliferation and differentiation capacity, further promoting ferroptosis (39). The C2C12 cell line, derived from murine satellite cells, is frequently used as an in vitro model for muscle differentiation and regeneration (62,63). When appropriately stimulated, these myoblasts can differentiate into mature myofibers (64). Liu et al (55) discovered that ferroptosis in C2C12 myoblasts accelerates skeletal muscle aging, with a notable reduction in the redox-active metabolite taurine, leading to iron metabolism dysregulation. This suggests that aging and ferroptosis may form a vicious cycle that mutually reinforces each other, although the underlying mechanisms require further investigation. Grevendonk et al (65) found that regular exercise training enhances physical activity levels and considerably counteracts aging, potentially through mechanisms associated with mitochondrial function decline, although ferroptosis was not explicitly addressed. However, Wang et al (56) demonstrated that lifelong aerobic exercise mitigates oxidative stress in aging skeletal muscle by activating the Keap1/nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway, thereby enhancing antioxidant enzyme activity. Conversely, detraining inhibits this pathway, resulting in increased oxidative stress and ferroptosis, ultimately compromising muscle mass and function, leading to muscle atrophy. These effects are particularly pronounced during the aging process. Furthermore, skeletal muscle dysfunction may also arise from various pathological conditions. For instance, chronic obstructive pulmonary disease (COPD), which commonly develops with aging, contributes to sarcopenia and skeletal muscle impairment (66). In a cigarette smoke-induced COPD mouse model, Myostatin expression was upregulated and induced ferroptosis in skeletal muscle cells via hypoxia inducible factor (HIF) 2 α (67). Therefore, the investigation of ferroptosis in skeletal muscle should not be limited to primary ferroptotic events within muscle tissue but should also consider ferroptosis induced by aging, systemic diseases and other physiological conditions. Collectively, research suggests that skeletal muscle aging is accompanied by increased susceptibility to ferroptosis, characterized by reduced GPX4 expression, altered iron handling (including TFRC decline) and heightened oxidative stress (39). Both intrinsic aging processes and external stressors, such as chronic disease and impaired antioxidant signaling, appear to converge on redox imbalance and mitochondrial dysfunction (68). Disruption of iron homeostasis and antioxidant defense may impair satellite cell maintenance and regenerative capacity, thereby contributing to age-related muscle decline (39). However, the majority of existing data are derived from animal models and in vitro systems, and direct validation in human aging muscle remains limited. Further studies are required to clarify whether ferroptosis represents a primary driver of muscle aging or a downstream consequence of systemic metabolic stress (39,68).

Sarcopenia

Sarcopenia is a systemic syndrome characterized by muscle atrophy, which is associated with an age-related decline in muscle mass and function. It is recognized as one of the leading causes of disability in the elderly (69), while also increasing the risk of falls and mortality (70). In a differential gene expression analysis comparing sarcopenic and normal muscle tissues, 46 ferroptosis-related genes were identified and found to be functionally enriched in key biological processes and KEGG signaling pathways, particularly those related to steroid hormone and glucocorticoid responses, carbon metabolism, ferroptosis and the glyoxylate metabolic pathway in sarcopenia. A total of 11 hub genes, Cdkn1a, Cs, DLD, Foxo1, Hspb1, Ldha, Mdh2 and Ywhaz, demonstrated high sensitivity and specificity for diagnosing sarcopenia, as derived from transcriptomic and network-based bioinformatics analyses conducted using established analytical frameworks (71). In a study by Huang et al (57) on ferroptosis in sarcopenia, the SAMP8 mouse model of accelerated aging was used, the study found that aged SAMP8 mice exhibited notable reductions in muscle mass and fiber density, along with an increased expression of ferroptosis-related markers in skeletal muscle. Moreover, iron overload was shown to induce ferroptosis, impairing the differentiation of C2C12 myoblasts into myotubes, reducing cell viability and promoting the accumulation of lipid peroxidation products. Mechanistically, this process was mediated by the p53-SLC7A11 signaling pathway (57). SLC7A11, a member of the solute carrier family 7, functions as an amino acid transporter involved in GSH biosynthesis (72). Iron overload upregulates p53 expression, which in turn inhibits SLC7A11 protein levels, leading to the accumulation of lipid peroxides and the induction of ferroptosis in muscle cells (57). Sarcopenia is frequently associated with various comorbidities. For instance, COPD is often accompanied by sarcopenia. A bioinformatics analysis identified SAA1 as a potential hub gene in COPD-associated sarcopenia, while the NF-κB signaling pathway was implicated in the underlying mechanism. Additionally, oxidative phosphorylation and ferroptosis were suggested to play key roles in the development of this comorbidity, based on published transcriptomic and computational analyses using standardized bioinformatics pipelines (73). Furthermore, studies have indicated that patients with multiple sclerosis may develop sarcopenia due to gut microbiota dysbiosis caused by hemodialysis (74). This suggests a considerable role for gut microbiota in the progression of sarcopenia. Recent research has also demonstrated that temperature fluctuations may influence gut microbiota, leading to increased serum levels of homocitrulline, which exacerbates ferroptosis and results in mitochondrial dysfunction in muscle cells (75,76). Notably, activation of the Nrf2 pathway was shown to mitigate heat exposure-induced ferroptosis-associated muscle atrophy (75). Additionally, a study by Liu et al (77) proposed that temperature fluctuations may impact muscle function via the gut-muscle axis, thereby contributing to sarcopenia progression. Taken together, emerging data indicate that ferroptosis may participate in the pathophysiology of sarcopenia through coordinated alterations in iron metabolism, p53-SLC7A11 signaling and mitochondrial oxidative stress. Transcriptomic analyses consistently identify ferroptosis-related gene enrichment in sarcopenic muscle, although these findings largely reflect associative bioinformatics evidence rather than direct functional validation. Moreover, comorbid conditions such as COPD, gut microbiota dysbiosis and environmental stress may amplify ferroptotic susceptibility, suggesting that sarcopenia represents a multifactorial state in which ferroptosis intersects with inflammatory and metabolic signaling. Future studies integrating human tissue validation and mechanistic intervention models are necessary to determine whether ferroptosis is a primary driver or a secondary consequence of muscle degeneration.

Skeletal muscle atrophy

Skeletal muscle atrophy is a systemic pathological condition that may result from multiple factors (77). The occurrence of muscle atrophy is characterized by a reduction in skeletal muscle size and thinning of muscle fibers (78). It can be broadly classified into two types: neurogenic and myogenic (79). Regardless of the type, muscle atrophy is invariably associated with a decline in muscle strength and mass, ultimately affecting patients' quality of life. Muscle atrophy is not an independent disease but rather a pathological condition that accompanies the progression of various diseases. Aging (80), immobilization (81), cancer (82), metabolic disorders (83) and neurodegenerative diseases have all been shown to contribute to muscle atrophy, often accompanied by the loss of collagen fibrin (84). Additionally, immobilization due to pain or postoperative recovery can lead to muscle atrophy (85). Following nerve injury, the control and nutritional support provided by nerves to muscles become impaired, further inducing muscle atrophy (86). Given that muscle atrophy frequently accompanies the onset and prognosis of various diseases, Ni et al (58) established a chronic kidney disease (CKD) mouse model and observed skeletal muscle dysfunction and atrophy, which was found to be associated with ferroptosis. In CKD, skeletal muscle atrophy, a common complication, has been found to be mitigated by caffeic acid, a natural phenolic compound, through inhibition of the TLR4/MYD88/NF-κB signaling pathway and ferroptosis (87). Moreover, Shenshuai Yingyang Jiaonang, a traditional Chinese herbal medicine, has been demonstrated to alleviate CKD-induced muscle atrophy by activating the HIF-1α/SLC7A11 pathway to inhibit ferroptosis (88). In patients with cancer undergoing cisplatin chemotherapy, although cisplatin effectively targets tumor cells, it has severe side effects, including muscle atrophy (89), which compromises muscle function. Programmed cell death protein 1 (PD-1), a membrane protein expressed on immune cells, plays a key role in immune responses and autoimmunity. Knockout of PD-1 induces considerable skeletal muscle atrophy and following chemotherapy, PD-1-deficient mice exhibit exacerbated muscle atrophy accompanied by inflammation and oxidative stress. Notably, genes related to ferroptosis and autophagy were notably upregulated in these models (90). Inflammation and oxidative stress are recognized as major risk factors for muscle atrophy. In a study by Sheng et al (91), sepsis was found to induce muscle atrophy and weakness. Microarray dataset analysis revealed notable enrichment of genes related to muscle function, ferroptosis and the p53 signaling pathway, based on published transcriptomic analyses using standardized bioinformatics pipelines. Additionally, targeting the inhibition of STAT6 was shown to ameliorate mitochondrial dysfunction, ferroptosis and CHI3L1-mediated satellite cell damage, thereby improving muscle atrophy and weakness. Furthermore, treatment with dihydromyricetin was found to restore muscle mass and function. The underlying mechanism primarily involved inhibiting excessive E3 ubiquitin-protein ligase activity, reducing malondialdehyde (MDA) levels and restoring superoxide dismutase and GPX activity. This led to a reduction in oxidative stress and ferroptosis, ultimately improving muscle atrophy (89). As muscle atrophy is a common complication in various diseases, research on its association with ferroptosis remains limited. While emerging evidence suggests a potential association between ferroptosis and muscle atrophy, further investigations are needed to elucidate their precise. Overall, available evidence suggests that ferroptosis may contribute to skeletal muscle atrophy across diverse pathological contexts, including CKD, chemotherapy, sepsis and inflammatory states. A recurring theme involves oxidative stress amplification, dysregulation of antioxidant defense systems and activation of ferroptosis-related signaling pathways. However, the several studies rely on transcriptomic enrichment analyses or pharmacological intervention models, and the temporal relationship between ferroptosis activation and muscle fiber loss remains incompletely defined (92-94). Clarifying whether ferroptosis acts as an initiating event or a downstream amplifier of muscle atrophy will be key for determining its therapeutic relevance.

Bone-related disorders and ferroptosis

Osteoporosis, osteoarthritis and lumbar IVD represent three interrelated degenerative skeletal disorders, all of which are closely linked to aging, altered mechanical loading and hormonal changes. Osteoporosis has been shown to accelerate the progression of both osteoarthritis and IVD. Conversely, the reduced mobility and mechanical unloading resulting from joint and disc degeneration can further exacerbate bone loss and promote the development of osteoporosis (Fig. 5).

Figure 5 Ferroptosis in skeletal system diseases. The figure illustrates the involvement of ferroptosis in osteoporosis, osteoarthritis and intervertebral disc degeneration. Iron accumulation, oxidative stress and GPX4 inhibition promote osteocyte loss, chondrocyte dysfunction and extracellular matrix degradation, contributing to disease progression. ROS, reactive oxygen species; GPX4, glutathione peroxidase 4. MMP, mitochondrial membrane potential; Piezo1, Piezo-type mechanosensitive ion channel component 1; AMPK, AMP-activated protein kinase; NCOA4, nuclear receptor coactivator 4.

Osteoporosis

Osteoporosis is a major risk factor for fractures, particularly in elderly individuals. It is characterized by reduced bone mineral density resulting from alterations in bone microarchitecture, rendering bones susceptible to fractures even under relatively low-impact forces. Although aging and decreased levels of sex hormones are well-known contributors to osteoporosis, it may also occur secondary to various pathological conditions (95-97). Thus, osteoporosis is not limited solely to the elderly population (98). Ferroptosis, a form of regulated cell death driven by iron-dependent lipid peroxidation, has been identified as a key mechanism underlying osteoblast impairment in osteoporosis (99). Smoking is a recognized risk factor for osteoporosis and has been associated with ferroptosis-related bone homeostasis disruption. Jing et al (100) demonstrated that smoking increases ROS levels in bone marrow mesenchymal stem cells (BMSCs), leading to activation of the AMPK signaling pathway. This, in turn, promotes NCOA4-mediated ferritinophagy, resulting in elevated intracellular iron levels and lipid peroxidation, ultimately triggering ferroptosis and contributing to osteoporotic pathology. Ferroptosis in BMSCs may impair their osteogenic differentiation potential and simultaneously enhance osteoclast activation, further increasing the risk of osteoporosis. Enhanced osteoclastogenesis and bone resorption, processes frequently observed in osteoporosis, have also been associated with ferroptotic mechanisms (101). During aging, activating ATF3 promotes iron uptake by upregulating TFR1 and inhibits cystine import through suppression of SLC7A11, leading to iron overload and lipid peroxidation. This culminates in ferroptosis of osteocytes, cortical bone loss and ultimately contributes to osteoporosis development (46). Keap1 has been shown to modulate osteoblast ferroptosis through activation of the Nrf2/SLC7A11/GPX4 signaling axis, providing a potential therapeutic avenue for osteoporosis (99). Estrogen deficiency, particularly postmenopause, promotes iron accumulation in bone tissue and induces ferroptosis in osteocytes, making ferroptosis a promising therapeutic target for postmenopausal osteoporosis (102). Moreover, osteoporosis is a notable complication in patients with diabetes. Recent studies have revealed that elevated levels of ferroptosis in diabetic conditions impair the osteogenic commitment and differentiation of BMSCs, leading to marked skeletal abnormalities (103-105). Collectively, ferroptosis has been implicated to varying extents in osteoporosis of diverse etiologies, highlighting its potential as a mechanistic focus for future research into osteoporosis pathogenesis. Current research indicates that ferroptosis participates in osteoporosis across diverse etiologies, including aging, estrogen deficiency, smoking exposure and diabetes-associated metabolic dysfunction. A recurring mechanistic pattern involves iron accumulation, ferritinophagy activation, oxidative stress amplification and impairment of osteoblast or osteocyte viability. However, the majority of studies are based on animal models or in vitro BMSC systems, and the temporal relationship between ferroptosis activation and structural bone loss remains to be fully established (106,107). Whether ferroptosis represents a primary pathogenic driver or a secondary response to metabolic and hormonal imbalance warrants further investigation.

IVDD

IVDD is one of the most prevalent degenerative conditions affecting the spine and is considered a major contributor to various lumbar disorders, with a prevalence of 71% in men and 77% in women <50 years of age and >90% in individuals aged 50 years and older (108). Among these, lumbar disc herniation (LDH) represents a typical manifestation (109). The senescence of fibrochondrocytes within the intervertebral disc and the consequent reduction in proteoglycan synthesis led to disc dehydration and collapse. This structural deterioration increases the mechanical stress on the annulus fibrosus, eventually causing the nucleus pulposus to herniate through annular fissures, thereby initiating LDH (110). Excessive mechanical loading is widely recognized as a key pathogenic factor in IVDD (111,112). Such loading activates the mechanosensitive ion channel Piezo1, located on the plasma and endoplasmic reticulum membranes, resulting in elevated intracellular Ca2+ levels. This, in turn, induces ferroptosis and endoplasmic reticulum stress (113). Xiang et al (114) further demonstrated an association between IVDD and ferroptosis, identifying key oxidative stress-related differentially expressed genes, including HMOX1, KEAP1, MAPK1, HSPA5, TXNRD1, IL6, PPARA, JUN, HIF1A and DUSP1. The principal signaling pathways implicated were the TNF signaling pathway, HIF-1 signaling pathway, NOD-like receptor signaling pathway and IL-17 signaling pathway. Additionally, a downregulation of sirtuin (SIRT) 3 expression has been observed during IVDD progression. An in vivo knockout study revealed that loss of SIRT3 exacerbates disc degeneration and pain symptoms (115). SIRT3 is considered to mitigate mitochondrial autophagy via the PINK1/Parkin signaling pathway and is closely associated with ubiquitination processes (115). While IVD is an age-related physiological process, proactive strategies to delay or prevent disc degeneration may be effective in reducing the incidence and progression of related spinal disorders (116). Taken together, available studies suggest that ferroptosis may contribute to IVD through mechanisms involving mechanical stress-induced calcium influx, oxidative stress-related gene dysregulation and mitochondrial dysfunction (113). Activation of Piezo1 signaling and alterations in SIRT3 expression appear to represent important regulatory nodes linking mechanical loading to redox imbalance (117). Nevertheless, current evidence is largely derived from transcriptomic analyses and experimental models, and direct clinical validation in human disc tissue remains limited (118). Further studies are required to clarify the causal contribution of ferroptosis to disc structural failure and pain progression.

Osteoarthritis (OA)

The pathogenesis of OA initially manifests at the level of articular cartilage. Early cartilage matrix degradation, particularly of collagen, prompts the proliferation and clustering of chondrocytes, leading to the formation of osteophytes (119). This is accompanied by the production of pro-inflammatory mediators and progressive cartilage erosion, ultimately resulting in joint destruction and the onset of OA (98). Iron homeostasis plays a pivotal role in maintaining the health of articular cartilage. Excessive iron accumulation induces oxidative stress and ferroptosis in chondrocytes, thereby contributing to the development of arthritis (120). Ferroptosis not only impairs chondrocyte function but also activates inflammatory signaling pathways, creating a vicious cycle that accelerates joint inflammation. Single-cell RNA sequencing comparing healthy cartilage and osteoarthritic cartilage revealed a considerable increase in both inflammatory and fibrocartilage-like chondrocyte populations in OA tissues, with enrichment of genes involved in ferroptosis pathways (121), based on published transcriptomic analyses using standardized bioinformatics pipelines. Furthermore, a study by Xie et al (122) demonstrated that the antioxidant compound JP4-039 attenuates OA progression by promoting PINK1/Parkin-dependent mitophagy, thereby protecting chondrocytes from ferroptotic cell death. Iron overload catalyzes the generation of ROS through mitochondrial dysfunction, which inhibits type II collagen expression and promotes the expression of matrix-degrading enzymes such as MMPs and ADAMTS. This enzymatic activity leads to the degradation of collagen and proteoglycans, compromising the structural integrity of cartilage (120). Excessive mechanical loading is also an important risk factor for OA, wherein the mechanosensitive ion channel Piezo1 contributes to disease progression by modulating ferroptosis in chondrocytes (5). Therefore, early therapeutic intervention targeting ferroptosis holds promise for the effective treatment of OA (123). Overall, current data support a contributory role of ferroptosis in osteoarthritis, particularly through iron-induced oxidative stress, mitochondrial dysfunction and inflammatory amplification in chondrocytes. Enrichment of ferroptosis-related genes in single-cell transcriptomic analyses and protective effects of ferroptosis-targeting interventions suggest mechanistic relevance. However, much of the evidence remains associative and the extent to which ferroptosis precedes or follows cartilage matrix degradation is not yet fully defined. Clarifying the sequence and cell-type specificity of ferroptotic events will be key for translating these findings into therapeutic strategies.

Aging is characterized by progressive dysregulation of both iron metabolism and antioxidant defenses, which together create a permissive environment for ferroptotic susceptibility in musculoskeletal tissues. Age-related increases in intracellular iron content have been observed in skeletal muscle and bone, which can promote oxidative damage through enhanced Fenton chemistry and lipid peroxidation, thereby impairing mitochondrial function and cellular homeostasis (124). Such iron accumulation is accompanied by a decline in GSH synthesis and activity of GPX4 and other endogenous antioxidant systems, weakening cellular capacity to neutralize ROS and lipid peroxides. In addition, age-associated impairment of iron export and storage mechanisms, such as reduced expression of ferroportin and altered ferritin dynamics, may further contribute to iron retention and redox imbalance. Together, these age-related changes in iron handling and antioxidant capacity may sensitize muscle cells, tendon-derived cells, chondrocytes and osteocytes to ferroptotic injury, thus intersecting with and potentially accelerating musculoskeletal decline (125).

Disease-oriented modeling and pharmacological modulation of ferroptosis in musculoskeletal systems

In vitro ferroptosis models are not merely experimental tools but represent essential platforms for understanding disease-specific mechanisms and evaluating therapeutic strategies in musculoskeletal disorders. In the context of tendon degeneration, muscle atrophy, cartilage degeneration and bone remodeling, ferroptosis-related cellular models provide key insights into how iron metabolism dysregulation, oxidative stress and lipid peroxidation contribute to tissue dysfunction, regenerative failure and progressive degeneration (126). Therefore, these models are discussed not as isolated experimental systems, but as disease-oriented platforms that integrate mechanistic investigation with translational relevance in musculoskeletal pathology.

At the level of pathological microenvironment modeling, ferroptosis can be induced by mimicking iron overload and oxidative stress conditions characteristic of degenerative musculoskeletal tissues. In the study conducted by Huang et al (57), ferric ammonium citrate was used to treat undifferentiated C2C12 myoblasts, differentiated C2C12 myotubes and cells undergoing differentiation, successfully inducing ferroptosis, thereby providing a model that reflects iron accumulation-driven cellular injury in muscle degeneration. Similarly, hydrogen peroxide (H2O2) is frequently used in oxidative stress and aging models relevant to musculoskeletal disorders. Importantly, studies have demonstrated that ferrostatin-1 (Fer-1) can effectively reverse cell death induced by H2O2, suggesting that H2O2-induced injury partially involves ferroptotic mechanisms (43). These models simulate disease-relevant microenvironmental stressors and provide a biologically meaningful context for studying ferroptosis in musculoskeletal degeneration.

At the level of molecular mechanism-oriented modeling, classical ferroptosis inducers target core regulatory nodes of ferroptotic signaling. Erastin, a commonly used ferroptosis inducer, inhibits the Xc− system, leading to reduced cystine uptake, depletion of intracellular GSH, impairment of antioxidant defenses and subsequent lipid peroxidation-driven cell death. In addition, erastin can induce ROS generation and activate p53 signaling, which further suppresses SLC7A11 expression, reinforcing Xc− system inhibition and amplifying ferroptotic vulnerability (27). RSL3 represents another mechanistically distinct ferroptosis inducer. Although traditionally regarded as a GPX4 inhibitor, Dorian et al (127) demonstrated that RSL3 induces ferroptosis primarily through potent inhibition of thioredoxin reductase 1 (TXNRD1), thereby revealing an alternative redox regulatory axis in ferroptotic control. Together, these models enable precise dissection of ferroptosis-regulatory networks that are highly relevant to redox imbalance and metabolic dysregulation in musculoskeletal diseases.

At the level of pharmacological modulation, ferroptosis inhibitors provide essential tools for evaluating the therapeutic potential of ferroptosis-targeted interventions. Fer-1 is widely employed as a canonical ferroptosis inhibitor and acts by scavenging phospholipid hydroperoxyl radicals, thereby interrupting lipid peroxidation chain reactions and stabilizing membrane integrity. Comparative analyses by Miotto et al (128) demonstrated that although both Fer-1 and Trolox exhibit chain-breaking antioxidant activity, Fer-1 shows superior efficacy in inhibiting lipid peroxidation. Unlike conventional antioxidants that are consumed during redox reactions, Fer-1 forms a catalytic-like redox cycle through complex formation with Fe2+, enabling sustained ferroptosis inhibition (118). Consistently, Rachid et al (129) reported that Fer-1 prevents ferroptotic cell death by protecting membrane lipids without interfering with mitochondrial ROS production or lysosomal membrane permeability, supporting its mechanistic specificity in ferroptosis modulation.

Importantly, the sensitivity of different cell types to ferroptosis inducers and inhibitors varies substantially, and their molecular targets are not universally conserved across tissues. This heterogeneity highlights the necessity of disease- and tissue-specific selection of experimental ferroptosis models and pharmacological agents, particularly in the musculoskeletal system, where cellular phenotypes, metabolic profiles and vascularization levels differ markedly among muscle, tendon, cartilage and bone tissues.

Collectively, these in vitro ferroptosis models should not be viewed as isolated experimental systems, but as disease-oriented platforms that bridge mechanistic research and translational application. While current ferroptosis inducers and inhibitors are indispensable for mechanistic dissection, the majority remain research-grade tools rather than clinically applicable agents. Their translational limitations include limited target specificity, poor bioavailability, lack of tissue-selective delivery and restricted applicability in low-vascularized musculoskeletal tissues such as tendons and cartilage. These challenges underscore the necessity of integrating disease-specific modeling with pharmacological optimization and targeted delivery strategies, thereby transforming experimental ferroptosis models into translational platforms for musculoskeletal therapy development (Table II).

Table II Ferroptosis related model (in vitro).

Table II

Ferroptosis related model (in vitro).

A, Inducers
Authors, year	Cells	Compound	(Refs.)
Wu et al, 2022	Tenocytes	RSL3	(49)
Gao et al, 2024	TSPCs (tendon stem cells)	H2O2	(43)
Huang et al, 2021	C2C12 myoblasts, C2C12 myotubes	Ferric citrate, erastin	(57)
Ni et al, 2023	C2C12 myoblasts, C2C12 myotubes	Indolyl sulfate	(58)
Wang et al, 2021	C2C12 myoblasts	RSL3	(61)
Liu et al, 2022	BMSCs	Erastin, RSL3	(138)
Jiang et al, 2024	Ocy454 cell line	FAC	(102)
Wan et al, 2023	Chondrocyte	Erastin	(135)
Xie et al, 2025	Chondrocytes	Tert-Butyl Hydroperoxide, TBHP	(122)
B, Inhibitors
Authors, year	Cells	Compound	(Refs.)
Wang et al, 2023	Tendon-derived stem cells	Ferrostatin-1 (Fer-1)	(42)
Gao et al, 2024	Tendon stem/progenitor cells	Fer-1	(43)
Huang et al, 2021	C2C12 myoblasts, C2C12 myotubes	Fer-1, Deferoxamine	(57)
Ni et al, 2023	C2C12 myoblasts, C2C12 myotubes	Lobetyolin	(58)
Zhang et al, 2022	C2C12 myotubes	UAMC-3203	(67)
Jing et al, 2023	Bone marrow mesenchymal stem cells	Fer-1, DFO	(100)
Jiang et al, 2024	Ocy454 cell line	Lip-1, Fer-1	(102)

[i] RSL3, RAS-selective lethal 3; H₂O₂, hydrogen peroxide; FAC, ferric ammonium citrate; TBHP, Tert-Butyl Hydroperoxide; Fer-1, ferrostatin-1; DFO, Deferoxamine; Lip-1, liproxstatin-1.

While pharmacological inducers and inhibitors provide valuable tools for manipulating ferroptosis and exploring its therapeutic potential, these compounds primarily target downstream execution pathways, such as lipid peroxidation and antioxidant defense systems. However, ferroptosis is also tightly regulated at the post-translational level through dynamic modifications of key proteins involved in iron metabolism, redox balance and mitochondrial function. Understanding how post-translational modifications (PTMs) modulate ferroptosis-related signaling networks offers a deeper mechanistic perspective beyond compound-based intervention and provides insight into endogenous regulatory complexity. Therefore, the following section focuses on the role of PTMs in fine-tuning ferroptotic processes in musculoskeletal contexts.

Ferroptosis and post-translational modifications

PTMs represent a decisive regulatory layer that integrates upstream stress signals and determines ferroptotic cell fate through dynamic modulation of key proteins involved in iron metabolism, lipid peroxidation and antioxidant defense. Unlike transcriptional regulation, which alters gene expression at the mRNA level, PTMs provide rapid, reversible and spatially restricted control over protein stability, enzymatic activity and subcellular localization. In musculoskeletal tissues, where mechanical loading, metabolic imbalance, inflammatory signaling and aging-related oxidative stress frequently intersect, PTM-mediated fine-tuning may function as a key checkpoint that dictates ferroptosis susceptibility. Therefore, PTMs should not be viewed merely as molecular decorations, but as core regulatory nodes that connect upstream pathological stimuli with downstream ferroptotic execution mechanisms (Fig. 6).

Figure 6 Post-translational modifications regulating ferroptosis in musculoskeletal disorders. The diagram highlights key post translation modifications, including ubiquitination, phosphorylation, methylation and acetylation, which modulate the stability, activity and localization of ferroptosis-related proteins. These modifications act as regulatory nodes linking upstream stress signals to ferroptotic cell death. MYSM1, Myb-like, SWIRM and MPN domain-containing protein 1; TRIM8, tripartite motif containing 8; USP11, ubiquitin specific peptidase 11; BMP9, bone morphogenetic protein 9; PD-1, programmed cell death protein 1; Nestin, neuroepithelial stem cell protein; SIRT1, sirtuin 1; HDAC4, histone deacetylase 4; HDAC5, histone deacetylase 5; p50, nuclear factor NF-kappa-B p50 subunit; p65, transcription factor p65.

Ubiquitination

Ubiquitination is a key post-translational modification that regulates protein synthesis, stability and degradation, thereby influencing cellular sensitivity to ferroptosis. This process plays a vital role in maintaining bone cell function and skeletal metabolic homeostasis. MYSM1, a histone deubiquitinase, has been shown to promote osteogenic differentiation, its deficiency leads to increased osteoclast number and activity, disrupts hematopoietic stem cell (HSC) function and heightens HSC susceptibility to ferroptosis, contributing to bone marrow failure syndromes. Mechanistically, MYSM1 deficiency reduces the translational efficiency of GPX4, a key ferroptosis suppressor and may also impair the recruitment of essential transcription factors such as Gata2 and Runx1 (130). Ubiquitination also contributes to ferroptosis regulation in the context of arthritis. For example, P21 modulates the mono-ubiquitination level of GPX4, indirectly affecting chondrocyte sensitivity to ferroptosis (131). TRIM8, via its RING domain, facilitates the ubiquitination and subsequent degradation of YTHDF2, thereby influencing chondrocyte ferroptosis and modulating arthritis progression (132). In studies on IVDD, Zhu et al (115) reported that the deubiquitinase USP11 alleviates oxidative stress-induced ferroptosis through deubiquitination mechanisms. Similarly, Huang et al (105) found that BMP9 alleviates iron accumulation-induced osteoporosis by upregulating USP10, which removes K48-linked polyubiquitin chains from FOXO1. This action prevents excessive cytoplasmic ubiquitination of FOXO1 and promotes GPX4 expression, thereby reducing ferroptosis. Aberrant expression of E3 ubiquitin ligases is closely associated with ferroptosis in musculoskeletal diseases (89), with PD-1 playing a regulatory role in this context (90). SMURF, identified as the E3 ligase for FTH1, activates ferroptosis signaling and inhibits myoblast differentiation into myotubes (133). Nestin, a cytoskeletal protein, has been recognized as a key regulator of the ferroptosis-autophagy crosstalk in skeletal muscle atrophy. It interacts with MAP1LC3B (LC3B) and catalyzes its polyubiquitination at lysine-51, reducing LC3B availability for autophagy and thereby suppressing ferroptotic cell death (134). Moreover, the transcription factor Nrf2, a master regulator of antioxidant responses, is itself regulated by Keap1-mediated ubiquitin-dependent degradation. This regulatory axis represents a promising direction for future investigations into ferroptosis-related musculoskeletal pathologies. Collectively, ubiquitination acts as a protein stability checkpoint that determines the turnover of key ferroptosis regulators such as GPX4, FTH1 and transcription factors. By controlling degradation dynamics, ubiquitination establishes a threshold for ferroptotic activation in musculoskeletal cells.

Phosphorylation

Phosphorylation, a post-translational modification in biological systems, wherein phosphate groups are covalently attached to proteins or other biomolecules under enzymatic catalysis. This modification profoundly influences protein activity, subcellular localization and interaction networks, thereby modulating numerous cellular pathways. In a study by Xue et al (101), inhibition of I-κB and p65 phosphorylation was shown to suppress activation of the NF-κB signaling pathway, indicating that phosphorylation plays a key regulatory role in inflammatory responses. Similarly, Chen et al (9) demonstrated that phosphorylation of AMPK is essential for regulating cellular energy metabolism, antioxidant defense and regeneration. By modulating the AMPK/Nrf2/GPX4 signaling axis, AMPK phosphorylation delays the senescence of TSPCs, inhibits ferroptosis and enhances tendon regeneration. Phosphorylation also plays a pivotal role in ferroptosis associated with IVDD. For instance, PDK4 phosphorylates the E1α subunit of the pyruvate dehydrogenase complex, thereby inhibiting pyruvate decarboxylation and regulating cellular energy metabolism and lipid biosynthesis (123). Wan et al (135) found that induction of AMPKα phosphorylation in chondrocytes enhances its stability and activity and that activation of the AMPK/Nrf2/HO-1 pathway attenuates ferroptosis, offering a potential therapeutic strategy for arthritis. Similarly, Zhou et al (136) reported that suppression of PI3K/Akt phosphorylation mitigates ferroptosis by enhancing antioxidant defenses through upregulation of GSH and GPX4, thereby preventing lipid peroxidation and relieving joint pain. In another study, Hyeon et al (137) demonstrated that donepezil alleviates skeletal muscle insulin resistance in obese mice by inhibiting inflammation and ferroptosis via the AMPK/FGF21 pathway. This effect was mainly attributed to suppression of NF-κB phosphorylation and I-κB degradation, leading to reduced expression of pro-inflammatory markers. Moreover, mutations in genes encoding phosphorylation-related enzymes or phospho-sites can disrupt phosphorylation dynamics, resulting in aberrant signaling and contributing to disease pathogenesis in musculoskeletal tissues. Taken together, phosphorylation functions as a rapid signal transduction mechanism that links metabolic and inflammatory stimuli to ferroptosis-related antioxidant pathways, thereby modulating cellular susceptibility to ferroptotic stress.

Methylation

Methylation refers to the enzymatic transfer of a methyl group from a donor molecule to specific substrates, a process typically catalyzed by methyltransferases. This epigenetic and epitranscriptomic modification plays a key role in gene expression regulation, RNA stability and cellular function, including the modulation of ferroptosis in musculoskeletal tissues. In a study by Liu (138), NSUN5, a member of the NOP2/Sun RNA methyltransferase family, was shown to play a pivotal role in regulating ferroptosis in BMSCs through the NSUN5-FTH1/FTL axis. Specifically, NSUN5 catalyzes 5-methylcytosine (m5C) modifications on the mRNA of FTH1 and FTL, and NSUN5 depletion results in a reduction of these modifications, subsequently leading to decreased expression of FTH1 and FTL, thereby promoting ferroptosis. Nrf2, a key regulator of antioxidant defense, also plays a central role in the modulation of ferroptosis in bone cells. Beyond its involvement in ubiquitination pathways, Nrf2 has been found to regulate DNA methylation of the receptor activator of nuclear factor κB ligand (RANKL) promoter via DNA methyltransferase 3a (Dnmt3a), thus influencing RANKL expression and osteoclastogenesis (102). Moreover, methyltransferase-like 3 (METTL3), an RNA N6-methyladenosine (m6A) methyltransferase, has emerged as a key modulator in chondrocyte ferroptosis. Depletion of METTL3 was shown to alleviate ferroptosis and cartilage damage, whereas its overexpression enhanced m6A methylation of HMGB1 mRNA, promoting ferroptotic responses (139). In models of diabetic osteoporosis induced by high glucose and high fat, METTL3 was found to activate the ASK1-p38 MAPK signaling pathway, thereby promoting ferroptosis in osteoblasts. Knockdown of METTL3 in MC3T3-E1 osteoblasts not only inhibited ASK1-p38 activation but also attenuated ferroptosis, highlighting METTL3 as a potential molecular target in diabetic bone loss (140). Furthermore, methylation directly impacts the expression and activity of ferroptosis-regulating enzymes. Inhibition of GPX4 methylation has been shown to mitigate ferroptosis in chondrocytes during arthritis progression (141). In ovariectomized mouse models of osteoporosis, reduced GPX4 expression was accompanied by hypermethylation of its promoter and elevated levels of DNA methyltransferases DNMT1, DNMT3a and DNMT3b (142). Although methylation has been widely studied in cancer and neurological diseases, its role in musculoskeletal disorders and ferroptosis is an emerging area of interest and warrants further exploration. Overall, methylation introduces an additional epigenetic and epitranscriptomic layer of regulation, influencing ferroptosis through long-term modulation of gene expression and mRNA stability, particularly in aging and metabolic disorders.

Acetylation

Acetylation is a form of post-translational protein modification involving the addition of an acetyl group to specific amino acid residues, most commonly lysine (143). This modification can considerably impact protein function, localization and interactions, thereby influencing diverse cellular processes, including ferroptosis. Recent studies have highlighted the regulatory role of acetylation in ferroptosis within musculoskeletal diseases (144,145). Overexpression of SIRT1, a class III histone deacetylase, promotes the expression of FTL by deacetylating it at lysine 181 (K181), which in turn suppresses ferroptosis in chondrocytes and attenuates the progression of arthritis (144,146). Histone deacetylases HDAC4 and HDAC5 also contribute to ferroptosis regulation by reducing acetylation of the tumor suppressor protein p53 at lysine 120 (K120). This deacetylation inhibits the activation of apoptotic and ferroptotic pathways, thereby preserving skeletal muscle cell viability and function under lipotoxic stress conditions (147). As such, acetylation-based regulatory mechanisms represent a promising avenue for future research in understanding and potentially targeting ferroptosis in musculoskeletal pathology. Acetylation-dependent regulation highlights the importance of metabolic-epigenetic crosstalk in ferroptosis control, suggesting that cellular acetyl-CoA availability and deacetylase activity may shape ferroptotic outcomes in musculoskeletal pathology.

Emerging PTMs such as SUMOylation, O-GlcNAcylation, lactylation and succinylation have recently been implicated in redox regulation and metabolic stress adaptation in other disease contexts. Although research associating these modifications to ferroptosis in musculoskeletal tissues remains limited, their established roles in regulating iron metabolism, mitochondrial function and antioxidant signaling suggest potential relevance. Future multi-omics and proteomics approaches may uncover additional PTM-mediated regulatory circuits that fine-tune ferroptotic susceptibility.

Therapeutic approaches for ferroptosis in muscular system disorders

Interorgan communication

Guan et al (148) demonstrated that the gut microbiota-derived metabolite capsiate (CAT) plays a regulatory role in ferroptosis induced by OA. Specifically, CAT targets HIF-1α to activate the expression of SLC2A1, thereby inhibiting ferroptosis and attenuating OA progression. This finding highlights the interorgan communication between the gut and the joints. Metabolites produced by the gut microbiota can reach joint tissues via the circulatory system or other pathways, thereby modulating the occurrence of ferroptosis in joint-resident cells. Despite its potential significance, research on interorgan communication in the context of ferroptosis and musculoskeletal diseases remains limited, particularly regarding the modulatory effects of gut microbial metabolites on musculoskeletal health.

Exosome therapy

Extracellular vesicles, also known as exosomes (EXOs), have been increasingly recognized as a promising tool for mitigating tendon aging, with potential applications in tissue regeneration and repair (9), and the purified exosomes can also improve the biomechanics of the rotator cuff (149). Platelet-derived EXOs exhibit anti-inflammatory properties and promote stem cell proliferation. In the study by Jin et al (150), it was found that systemic administration of bio-nanoparticles derived from human exfoliated deciduous teeth stem cell-derived EXOs (SHED-EXOs) effectively attenuated tendon degeneration in a naturally aging rat model and localized delivery of microspheres loaded with SHED-EXOs not only markedly reduced the accumulation of senescent cells and ectopic ossification but also restored the regenerative and reparative capacity of tendons in aged rats.

Pharmacological therapy

Celecoxib, a non-steroidal anti-inflammatory drug, has been reported to exert ferroptosis-inhibitory effects (151). When combined with lactoferrin, celecoxib enhances tendon repair. Zhang et al (50) conducted gene identification and bioinformatics analysis to explore the underlying mechanisms and identified Slc40a1, Tfrc and Cryab as ferroptosis-related genes key for regulating tendon injury repair (50), as indicated by published bioinformatics analyses. Lobetyolin, an active compound in traditional Chinese medicine, has been found to alleviate skeletal muscle damage by activating the Hedgehog signaling pathway, particularly the transcription factor Gli1, thereby upregulating a series of ferroptosis-inhibitory factors (58). Taurine, a redox-specific metabolite (152), has been shown to prevent ferroptosis by markedly increasing intracellular GSH levels, reducing MDA and ROS production and restoring the vitality of impaired myogenic differentiation. Taurine is also essential for glycerophospholipid metabolism, playing a key role in cell membrane repair. Additionally, it enhances mitochondrial bioenergetics, increasing the energy reserves produced by muscle satellite cells (55). Aconine is a natural compound that suppresses osteoclast activity and reduces bone resorption. It exerts its effects by inhibiting the NF-κB signaling pathway and modulating the expression of GPX4 and ACSL4, thereby regulating ferroptosis in osteoclasts (101). Biotin A (BCA), a naturally occurring isoflavonoid isolated from Astragalus membranaceus, exhibits anti-inflammatory and antioxidant properties. It directly reduces intracellular iron levels by inhibiting TfR1 and promoting FPN expression. In addition, BCA targets the Nrf2/system Xc−/GPX4 signaling pathway to scavenge free radicals and prevent lipid peroxidation (120). Selenium supplementation has been shown to alleviate endoplasmic reticulum stress by upregulating selenoprotein K (SelK) expression and reducing intracellular free Ca2+ concentrations. Through both the selenium-GPX4 and selenium-SelK axes, selenium mitigates ferroptosis induced by mechanical overload and contributes to the stabilization of the extracellular matrix (113).

Biomaterials and other approaches

Intramuscular injection of lentivirus expressing Tfr1 has been shown to mitigate Tfr1 deficiency-induced iron accumulation, thereby promoting skeletal muscle regeneration (39). Fer-1, a widely used ferroptosis inhibitor, upregulates CSE, thereby modulating the CSE/H2S signaling pathway, scavenging ROS and preventing lipid peroxidation. Hydrogen sulfide (H2S), a novel gaseous signaling molecule derived from CSE, is widely distributed across tissues and organs and plays a regulatory role in oxidative stress and lipid metabolism (61). Ferroptosis exhibits a dual role in cancer therapy. Zhang et al (153) designed a self-amplifying nanodrug (RCH NPs) using human serum albumin as a carrier to program the dual nature of ferroptosis. Within this system, ferric porphyrin-induced ferroptosis is coupled with celecoxib-mediated disruption of inflammation-related immune suppression, while roscovitine genetically blocks IFN-γ-induced PD-L1 upregulation. This strategy enhances the therapeutic potential of ferroptosis in tumor treatment. Regular physical exercise (65) and newly developed brain-muscle communication interventions that suppress detrimental central signals while stabilizing peripheral muscles to prevent muscle aging (154) may indirectly regulate ferroptosis, providing new directions for future research. In the study by Gao et al (155), a ROS-responsive injectable hydrogel, PVA-tsPBA@SLC7A11 modRNA, was developed to mitigate IVDD. Upon local injection into the degenerated disc, ROS-induced cleavage of the PVA-tsPBA hydrogel facilitated the release of encapsulated SLC7A11 modRNA, thereby suppressing ferroptosis in nucleus pulposus cells and ameliorating IVDD. In a separate study, Cit-AuNRs@Anti-TRPV1, a near-infrared (NIR)-activated nanoplatform, was shown to protect chondrocytes against ferroptosis under NIR irradiation and attenuate the progression of arthritis, offering a promising therapeutic strategy for joint diseases (156).

Future perspectives

Ferroptosis has emerged as a key pathogenic mechanism across a spectrum of musculoskeletal disorders, including skeletal muscle aging and atrophy, tendinopathy, osteoarthritis, IVDD and osteoporosis. Despite increasing research associating iron dysregulation, oxidative stress amplification and mitochondrial dysfunction to musculoskeletal tissue degeneration, several fundamental questions remain unresolved.

First, the temporal sequence of ferroptotic activation during tissue degeneration requires further clarification. It remains unclear whether ferroptosis functions as a primary driver of stem/progenitor cell dysfunction and extracellular matrix degradation or as a secondary amplifier of inflammatory and metabolic stress. Second, the interplay between ferroptosis and other cellular regulatory pathways, such as autophagy, warrants deeper investigation. For example, autophagy deficiency has been shown to mitigate erastin-induced ferroptosis (16), highlighting the importance of autophagy-dependent regulatory networks that may also be relevant in musculoskeletal tissues.

In addition, emerging evidence suggests potential crosstalk between ferroptosis and other forms of metal-associated regulated cell death. Xue et al (157) demonstrated that Cu2+ can enhance cellular susceptibility to ferroptosis by directly binding to GPX4 and promoting its ubiquitination and degradation. Although these findings were not limited to musculoskeletal models, they raise the possibility that metal homeostasis beyond iron may influence ferroptotic vulnerability in musculoskeletal pathology.

Future research should prioritize tissue-specific and stage-specific investigation of ferroptosis within the musculoskeletal system. Particular attention should be given to the interaction between mechanical loading, metabolic stress and ferroptotic signaling, as well as to the development of targeted therapeutic strategies for low-vascularized tissues such as tendon and cartilage. Integrating multi-omics approaches with functional validation in human tissues will be essential to translate ferroptosis-based interventions into clinically relevant therapies.

Overall, maintaining a focused mechanistic framework centered on musculoskeletal diseases will be critical for advancing both basic understanding and therapeutic innovation in this field.

Availability of data and materials

Not applicable.

Authors' contributions

WG was responsible for the writing, original draft of the manuscript. TX, FL and LY contributed to the writing, review and editing of the manuscript. FL responsible for preparation of figures. HZ and YY provided supervision and conceptualization of the present study. GW contributed to the conceptualization of the research and the acquisition of funding.

Ethics approval and consent to participate

Not applicable.

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

Not applicable.

Funding

The present study was supported by research grants from the Beijing Natural Science Foundation (grant no. 7262054) and the National Natural Science Foundation of China (grant no. NSFC 82171190). Additionally, Dr Wang's research has received funding through the Entrepreneurship and Innovation Program of Jiangsu Province (grant no. KYCX22_3383). Support was also received from the Shanghai Pujiang Program (grant no. 24PJD089) to Dr Haifeng Zhang.

References