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Muscle hypotrophy, not inhibition, is responsible for quadriceps weakness during rehabilitation after anterior cruciate ligament reconstruction

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Quadriceps weakness is common after anterior cruciate ligament reconstruction (ACLR). Limited neuromuscular activation may have a role in the weakness. The purpose of this study was to use peripheral magnetic stimulation to measure changes in quadriceps inhibition in patients during rehabilitation from ACLR.

Methods

Ten patients (7M/3F; age 35 ± 8 years; BMI 26.0 ± 4.8 kg/m2) who had ACLR with patellar tendon autograft were recruited. At 3 and 6 months postoperatively, patients’ knee extension peak torque was measured during maximum voluntary isometric contraction (MVIC), magnetic stimulation-evoked contraction, and MVIC augmented with superimposed burst magnetic stimulation to the femoral nerve. All tests were done bilaterally at 30° and 65° of knee flexion on a dynamometer. Central activation ratio was calculated by dividing the peak torque before stimulation by peak torque after stimulation.

Results

Patients had marked deficits in MVIC, with improvement from 3 to 6 months that was more apparent at 65° versus 30° (P < 0.05). There was significant deficit in stimulation-evoked torque on the involved side that diminished over time, and this change occurred differently between the two angles (P < 0.05). Central activation ratio was lower on the involved side versus the noninvolved side and this effect was more prominent at 3 versus 6 months: combining the angles, mean central activation ratio on the involved and noninvolved sides, respectively, was 91.4 ± 7.6% and 97.5 ± 5.3% at 3 months, and 93.0 ± 7.8% and 95.8 ± 6.8% at 6 months.

Conclusions

At 3 and 6 months after ACLR, there were significant deficits in quadriceps strength and activation. Quadriceps activation levels were high (> 90%) for both sides at both time points. The substantial strength deficits at this postoperative period may be largely due to muscle atrophy with limited contribution from central inhibition. Rehabilitation interventions to normalize quadriceps strength should emphasize hypertrophic stimuli as opposed to neuromuscular activation strategies.

Level of evidence

II, prospective cohort study.

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Funding

No funding has been received for this study.

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Authors and Affiliations

  1. Nicholas Institute of Sports Medicine and Athletic Trauma, Manhattan Eye, Ear, and Throat Hospital, 210 East 64th Sreet, New York, NY, 10065, USA

    Takumi Fukunaga, Christopher D. Johnson, Stephen J. Nicholas & Malachy P. McHugh

Authors
  1. Takumi Fukunaga
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  2. Christopher D. Johnson
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  3. Stephen J. Nicholas
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  4. Malachy P. McHugh
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Contributions

TF, CDJ, SJN, and MPM contributed to the study conception and design. TF and CDJ performed data collection. TF and MPM performed data analysis and interpretation, drafted the work, and made revisions. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Takumi Fukunaga.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the Institutional Review Board of Lenox Hill Hospital, New York, NY, USA (IRB# L06.02.013).

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Fukunaga, T., Johnson, C.D., Nicholas, S.J. et al. Muscle hypotrophy, not inhibition, is responsible for quadriceps weakness during rehabilitation after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 27, 573–579 (2019). https://doi.org/10.1007/s00167-018-5166-1

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  • DOI: https://doi.org/10.1007/s00167-018-5166-1

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