Troponin I (TnI) regulates thin filament activation and muscle contraction. Two isoforms, TnI-fast (
TNNI2
) and TnI-slow (
TNNI1
), are predominantly expressed in fast- and slow-twitch myofibers, respectively.
TNNI2
variants are a rare cause of arthrogryposis, whereas
TNNI1
variants have not been conclusively established to cause skeletal myopathy. We identified recessive loss-of-function
TNNI1
variants as well as dominant gain-of-function
TNNI1
variants as a cause of muscle disease, each with distinct physiological consequences and disease mechanisms. We identified three families with biallelic
TNNI1
variants (F1: p.R14H/c.190-9G>A, F2 and F3: homozygous p.R14C), resulting in loss of function, manifesting with early-onset progressive muscle weakness and rod formation on histology. We also identified two families with a dominantly acting heterozygous
TNNI1
variant (F4: p.R174Q and F5: p.K176del), resulting in gain of function, manifesting with muscle cramping, myalgias, and rod formation in F5. In zebrafish, TnI proteins with either of the missense variants (p.R14H; p.R174Q) incorporated into thin filaments. Molecular dynamics simulations suggested that the loss-of-function p.R14H variant decouples TnI from TnC, which was supported by functional studies showing a reduced force response of sarcomeres to submaximal [Ca
2+
] in patient myofibers. This contractile deficit could be reversed by a slow skeletal muscle troponin activator. In contrast, patient myofibers with the gain-of-function p.R174Q variant showed an increased force to submaximal [Ca
2+
], which was reversed by the small-molecule drug mavacamten. Our findings demonstrated that
TNNI1
variants can cause muscle disease with variant-specific pathomechanisms, manifesting as either a hypo- or a hypercontractile phenotype, suggesting rational therapeutic strategies for each mechanism.