Impaired Ability of Voluntary Quadriceps Activation Bilaterally Interferes with Function Testing after Knee Injuries. A Twitch Interpolation Study

Abstract

Central activation deficits have been recognised to be partially responsible for quadriceps muscle weakness after knee injuries effecting the injured as well as the uninjured leg. The purpose of this study was to assess the extent of bilateral activation deficits and its effect on functional muscle tests using the uninjured leg as reference. The study included 30 patients with isolated rupture of the anterior cruciate ligament (group 1), 42 patients with rupture of the anterior cruciate ligament and accompanying joint damage (group 2) and 34 healthy volunteers as reference. The maximum isometric knee extension torque and the maximal voluntary muscle activation (VA) were measured bilaterally using a sensitive twitch-interpolation method. The measured and the true functional deficit, adjusted to a physiological VA of the uninjured side, was calculated. Isolated rupture of the anterior cruciate ligament caused a minor VA-deficit and severe knee injuries more severe VA-deficits of the quadriceps muscles of the injured (VA group 1: 83.8 ± 1.9 %; group 2: 76.9 ± 1.8 %) and on the uninjured side (VA group 1: 85.9 ± 1.8 %; group 2: 77.9 ± 1.8 %) compared to the control group (VA 91 ± 0.64 %). Due to contralateral VA-deficits the mean underestimation of the isometric muscle-force deficit was 22 % in group 1 and 48% in group 2. Unilateral knee injuries lead to significant VA-deficits of the quadriceps muscles on both the injured and uninjured legs related to the severity of injury. The validity of tests for the assessment of muscle function is questionable when using the uninjured side as reference.

Key words

Anterior cruciate ligament - torque - arthrogenous muscle inhibition - maximal voluntary contraction - validity - isometric

References

• 1 Allen G M, Gandevia S C, McKenzie D K. Reliability of measurements of muscle strength and voluntary activation using twitch interpolation.  Muscle Nerve. 1995;  18 593-600
• 2 Andriacchi T P. Functional analysis of pre and post-knee surgery: total knee arthroplasty and ACL reconstruction.  J Biomech Eng. 1993;  115 575-581
• 3 Appelberg B, Hulliger M, Johansson H, Sojka P. Excitation of dynamic fusimotor neurones of the cat triceps surae by contralateral joint afferents.  Brain Res. 1979;  160 529-532
• 4 Arvidsson I, Eriksson E, Haggmark T, Johnson R J. Isokinetic thigh muscle strength after ligament reconstruction in the knee joint: results from a 5-10 year follow-up after reconstructions of the anterior cruciate ligament in the knee joint.  Int J Sports Med. 1981;  2 7-11
• 5 Awiszus F, Wahl B, Meinecke I. Influence of stimulus cross talk on results of the twitch-interpolation technique at the biceps brachii muscle.  Muscle Nerve. 1997;  20 1187-1190
• 6 Baugher W H, Warren R F, Marshall J L, Joseph A. Quadriceps atrophy in the anterior cruciate insufficient knee.  Am J Sports Med . 1984;  12 192-195
• 7 Bigland-Ritchie B R, Dawson N J, Johansson R S, Lippold O C. Reflex origin for the slowing of motoneurone firing rates in fatigue of human voluntary contractions.  J Physiol. 1986;  379 451-459
• 8 Bulow P M, Norregaard J, Danneskiold-Samsoe B, Mehlsen J. Twitch interpolation technique in testing of maximal muscle strength: influence of potentiation, force level, stimulus intensity and preload.  Eur J Appl Physiol.. 1993;  67 462-466
• 9 Denny-Brown D. On inhibition as a reflex accompaniment of the tendon jerk and of other forms of active muscular response.  Proc Roy Soc. 1928;  103 321-336
• 10        Dowling J J, Konert E, Ljucovic P, Andrews D M. Are humans able to voluntarily elicit maximum muscle force?.  Neurosci Lett. 1994;  179 25-28
• 11 Elmqvist L G, Lorentzon R, Johansson C, Fugl-Meyer A R. Does a torn anterior cruciate ligament lead to change in the central nervous drive of the knee extensors?.  Eur J Appl Physiol. 1988;  58 203-207
• 12 Fahrer H, Rentsch H U, Gerber N J, Beyeler C, Hess C W, Grunig B. Knee effusion and reflex inhibition of the quadriceps. A bar to effective retraining.  J Bone Joint Surg [Br.]. 1988;  70 635-638
• 13 Gauffin H, Pettersson G, Tegner Y, Tropp H. Function testing in patients with old rupture of the anterior cruciate ligament.  Int J Sports Med. 1990;  11 73-77
• 14 Hales J P, Gandevia S C. Assessment of maximal voluntary contraction with twitch interpolation: an instrument to measure twitch responses.  J Neurosci Methods. 1988;  25 97-102
• 15 Harter R A, Osternig L R, Standifer L W. Isokinetic evaluation of quadriceps and hamstrings symmetry following anterior cruciate ligament reconstruction.  Arch Phys Med Rehabil. 1990;  71 465-468
• 16 Hefti F, Muller W, Jakob R P, Staubli H U. Evaluation of knee ligament injuries with the IKDC form.  Knee Surg Sports Traumatol Arthrosc. 1993;  1 226-234
• 17 Hiemstra L A, Webber S, MacDonald P B, Kriellaars D J. Knee strength deficits after hamstring tendon and patellar tendon anterior cruciate ligament reconstruction.  Med Sci Sports Exerc. 2000;  32 1472-1479
• 18 Hurley M V, Jones D W, Newham D J. Arthrogenic quadriceps inhibition and rehabilitation of patients with extensive traumatic knee injuries.  Clin Sci. 1994;  86 305-310
• 19 Hurley M V, Jones D W, Wilson D, Newham D J. Rehabilitation of quadriceps inhibited due to isolated rupture of the anterior cruciate ligament.  J Orthop Rheum. 1992;  5 145-154
• 20 Johansson H, Sjolander P, Sojka P. Fusimotor reflexes in triceps sureae muscle elicited by  natural and electrical stimulation of joint afferents.  Neuro-Orthop. 1988;  6 67-80
• 21 Kannus P, Jarvinen M. Thigh muscle function after partial tear of the medial ligament compartment of the knee.  Med Sci Sports Exerc. 1991;  23 4-9
• 22 Kannus P, Yasuda K. Value of isokinetic angle-specific torque measurements in normal and injured knees.  Med Sci Sports Exerc. 1992;  24 292-297
• 23 Merton P A. Voluntary strength and fatigue.  J Physiol. 1954;  123 553-564
• 24 Natri A, Jarvinen M, Latvala K, Kannus P. Isokinetic muscle performance after anterior cruciate ligament surgery. Long-term results and outcome predicting factors after primary surgery and late-phase reconstruction.  Int J Sports Med. 1996;  17 223-228
• 25 Neugebauer V, Schaible H G. Evidence for a central component in the sensitization of spinal neurons with joint input during development of acute arthritis in cat's knee.  J Neurophysiol. 1990;  64 299-311
• 26 Newham D J, Hurley M V, Jones D W. Ligamentous knee injuries and muscle inhibition.  J Orthop Rheum. 1989;  2 163-173
• 27 Norregaard J, Lykkegaard J J, Bulow P M, Danneskiold-Samsoe B. The twitch interpolation technique for the estimation of true quadriceps muscle strength.  Clin Physiol. 1997;  17 523-532
• 28 Rutherford O M, Jones D A, Newham D J. Clinical and experimental application of the percutaneous twitch superimposition technique for the study of human muscle activation.  J Neurol Neurosurg Psychiatry. 1986;  49 1288-1291
• 29 Schaible H G, Neugebauer V, Cervero F, Schmidt R F. Changes in tonic descending inhibition of spinal neurons with articular input during the development of acute arthritis in the cat.  J Neurophysiol. 1991;  66 1021-1032
• 30 Shakespeare D T, Stokes M, Sherman K P, Young A. Reflex inhibition of the quadriceps after meniscectomy: lack of association with pain.  Clin Physiol. 1985;  5 137-144
• 31 Snyder-Mackler L, Ladin Z, Schepsis A A, Young J C. Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament. Effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles.  J Bone Joint Surg. 1991;  73 1025-1036
• 32 Spencer J D, Hayes K C, Alexander I J. Knee joint effusion and quadriceps reflex inhibition in man.  Arch Phys Med Rehabil. 1984;  65 171-177
• 33 Stokes M, Young A. The contribution of reflex inhibition to arthrogenous muscle weakness.  Clin Sci. 1984;  67 7-14
• 34 Urbach D, Awiszus F. Effects of transcranial magnetic stimulation on results of the twitch interpolation technique.  Muscle Nerve. 2000;  23 1125-1128
• 35 Urbach D, Nebelung W, Becker R, Awiszus F. Loss of function of the quadriceps femoris muscle after extensive knee injuries by voluntary activation deficit.  Unfallchirurg. 2000;  103 949-955
• 36 Urbach D, Nebelung W, Weiler H T, Awiszus F. Bilateral deficit of voluntary quadriceps muscle activation after unilateral ACL tear.  Med Sci Sports Exerc. 1999;  31 1691-1696
• 37 Yue G H, Ranganathan V K, Siemionow V, Liu J Z, Sahgal V. Evidence of inability to fully activate human limb muscle.  Muscle Nerve. 2000;  23 376-384