Quadriceps Weakness,Atrophy,and Activation Failure in Predicted Noncopers After Anterior Cruciate Ligament Injury

Abstract

Background: Quadriceps weakness is common after anterior cruciate ligament injury, especially in those who do not compensate well for the injury (“noncopers”). Both atrophy and activation failure have been demonstrated in this population but have not been directly related to quadriceps weakness.

Hypotheses: (1) Quadriceps strength, volumes, and cross-sectional areas of the noncopers would be smaller than those of the contralateral muscles, whereas other muscles would not demonstrate atrophy. (2) Quadriceps muscle activation deficits would be observed. (3) Atrophy and activation failure would account for the quadriceps weakness in these patients.

Study Design: Cross-sectional study, Level of evidence, 3.

Methods: Seventeen noncopers with isolated anterior cruciate ligament injury underwent burst-superimposition strength and activation testing of the quadriceps and magnetic resonance imaging of 12 muscles an average of 2 months after injury. Morphological characteristics was described by digitally reconstructing each muscle from the axial images and calculating muscle volume and peak cross-sectional area.

Results: The quadriceps muscles of the anterior cruciate ligament-deficient limb were significantly weaker (average 25%) than those of the uninjured side; activation failure (8%-10%) was observed for the quadriceps muscles of both limbs. The total quadriceps, vastus lateralis, and vastus intermedius volume and cross-sectional area were significantly smaller in the anterior cruciate ligament-deficient limb. There was no significant atrophy of any other muscle or muscle group. Atrophy and activation failure explained more than 60% of the variance in quadriceps weakness (P = .004).

Conclusion: The quadriceps femoris weakens soon after acute anterior cruciate ligament injury. Activation deficits and atrophy occur and affect quadriceps strength. Rehabilitation techniques that address activation deficits as well as atrophy may be necessary to restore quadriceps strength.

Keywords

knee morphology inhibition athletes

Get full access to this article

View all access options for this article.

References

Chmielewski TL

Stackhouse S

Axe MJ

et al.

A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture. J Orthop Res.2004:25;925-930.

DeVita P

Hortobagyi T

Barrier J

. Gait biomechanics are not normal after anterior cruciate ligament reconstruction and accelerated rehabilitation. Med Sci Sports Exerc.1998;30:1481-1488.

Eastlack ME

Axe MJ

Snyder-Mackler L

. Laxity, instability, and functional outcome after ACL injury: copers versus noncopers. Med Sci Sports Exerc.1999;31:210-215.

Elmqvist LG

Lorentzon R

Johansson C

et al.

Does a torn anterior cruciate ligament lead to change in the central nervous drive of the knee extensors?

Eur J Appl Physiol Occup Physiol.1988;58:203-207.

Fitzgerald GK

Axe MJ

Snyder-Mackler L

. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc.2000;8:76-82.

Fitzgerald GK

Axe MJ

Snyder-Mackler L

. Proposed practice guidelines for nonoperative anterior cruciate ligament rehabilitation of physically active individuals. J Orthop Sports Phys Ther.2000;30:194-203.

Fukunaga T

Miyatani M

Tachi M

et al.

Muscle volume is a major determinant of joint torque in humans. Acta Physiol Scand.2001;172:249-255.

Geiger B. Three-Dimensional Modeling of Human Organs and Its Application to Diagnosis and Surgical Planning [PhD thesis]. Rocquencourt, France: Institut National de Recherche en Informatique et Automatique; 1993.

Gerber C

Hoppeler H

Claassen H

et al.

The lower-extremity musculature in chronic symptomatic instability of the anterior cruciate ligament. J Bone Joint Surg Am.1985;67:1034-1043.

10.

Johansson H

Sjolander P

Sojka P

. Activity in receptor afferents from the anterior cruciate ligament evokes reflex effects on fusimotor neurones. Neurosci Res.1990;8:54-59.

11.

Kent-Braun JA

Le Blanc R

. Quantitation of central activation failure during maximal voluntary contractions in humans. Muscle Nerve.1996;19:861-869.

12.

Konishi Y

Fukubayashi T

Takeshita D

. Mechanism of quadriceps femoris muscle weakness in patients with anterior cruciate ligament reconstruction. Scand J Med Sci Sports.2002;12:371-375.

13.

Konishi Y

Fukubayashi T

Takeshita D

. Possible mechanism of quadriceps femoris weakness in patients with ruptured anterior cruciate ligament. Med Sci Sports Exerc.2002;34:1414-1418.

14.

Konishi Y

Konishi H

Fukubayashi T

. Gamma loop dysfunction in quadriceps on the contralateral side in patients with ruptured ACL. Med Sci Sports Exerc.2003;35:897-900.

15.

Kremer JR

Mastronarde DN

McIntosh JR

. Computer visualization of three-dimensional image data using IMOD. J Struct Biol.1996;116:71-76.

16.

Lewek M

Rudolph K

Axe M

et al.

The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon).2002;17:56-63.

17.

Lorentzon R

Elmqvist LG

Sjostrom M

et al.

Thigh musculature in relation to chronic anterior cruciate ligament tear: muscle size, morphology, and mechanical output before reconstruction. Am J Sports Med.1989;17:423-429.

18.

Okuyama R

Honda M

Fujiya H

et al.

Expression of heat shock protein 72 in rat quadriceps muscles following anterior cruciate ligament resection. J Orthop Sci.2003;8:213-217.

19.

Rudolph KS

Axe MJ

Buchanan TS

et al.

Dynamic stability in the anterior cruciate ligament deficient knee. Knee Surg Sports Traumatol Arthrosc.2001;9:62-71.

20.

Rudolph KS

Eastlack ME

Axe MJ

et al.

Movement patterns after anterior cruciate ligament injury: a comparison of patients who compensate well for the injury and those who require operative stabilization. J Electromyogr Kinesiol.1998;8:349-362.

21.

Schroeder W

Martin K

Lorensen B

. The Visualization Toolkit. 2nd ed.Upper Saddle River, NJ: Prentice Hall, Inc; 1997.

22.

Snyder-Mackler L

De Luca PF

Williams PR

et al.

Reflex inhibition of the quadriceps femoris muscle after injury or reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am.1994;76:555-560.

23.

Urbach D

Awiszus F

. Impaired ability of voluntary quadriceps activation bilaterally interferes with function testing after knee injuries: a twitch interpolation study. Int J Sports Med.2002;23:231-236.