Consequences of a ligament injury on neuromuscular function and relevance to rehabilitation — using the anterior cruciate ligament-injured knee as model

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Abstract

The purpose of this article is to survey current knowledge concerning the consequences of a ligament injury on neuromuscular function and its relevance to rehabilitation, in relation to clinical practice. Although it deals with the ACL-injured knee, these views may also apply to other joints. The effects of a ligament injury on neuromuscular function are first considered — i.e., proprioception, postural control, muscle strength, functional performance, movement and activation pattern, central mechanisms, motor control and learning. The treatment and effects of rehabilitation on neuromuscular function are then discussed. The survey is concluded by discussing the clinical significance.

Introduction

The anterior cruciate ligament (ACL) is the commonest ligament injured in the knee, and several studies have evaluated the consequences of such an injury. Rehabilitation programs formerly focused mainly on restoration of muscle strength, but during the last 10 years, the sensory function of ligaments in relation to functional joint stability has been regarded as important in rehabilitation after a ligament injury. Even though this review deals with the lower extremity and knee, the views expressed here may apply to other joints as well and should be of interest for treatment of a ligament injury.

Section snippets

Consequences of a ligament injury on neuromuscular function

The visual, vestibular and somatosensory systems contribute afferent information to the central nervous system (CNS) regarding body position and balance [71]. This neural input is integrated by the CNS to generate a motor response. Sensory receptors are present in the skin, muscles, joints, ligaments and tendons. Since a ligament injury causes a disturbance in the somatosensory system it may affect the central programs and motor response.

Relevance to rehabilitation

The development of rehabilitation programs after an ACL injury or reconstruction is based on theoretical models and clinical experience, and the aims are to restore joint motion, regain muscle strength and function to the preinjury level or a modified level of activity. Some authors report that active rehabilitation is performed for 5–8 months after an ACL injury [38], [86] and up to 1 year after an ACL reconstruction [38], [52].

An efficient function of the leg, hip and trunk muscles is needed

Conclusions

An ACL injury causes changes in neuromuscular function. Several studies show persistent weakness of the quadriceps and a reduction in functional performance, but others report that quadriceps strength and performance is restored. Strength of the hamstring muscles can be restored. Several studies report persistent impairment of proprioception or postural control, while few report normal values. The increase in knee joint laxity after an ACL injury does not correlate with functional outcome,

Eva Ageberg graduated from Lund University, Sweden in 1992. From 1994 she has worked at the Physical Medicine Unit, Department of Rehabilitation, Lund University Hospital. She has specialized in Physiotherapy in Orthopedics, and received her MSc in Physical Therapy in 1998. Her postgraduate studies at the Institute for Musculoskeletal Diseases, Department of Physical Therapy, Lund University, involve assessment of neuromuscular function, mainly postural control, and effects of rehabilitation in

References (90)

  • D.J Beard et al.

    Home or supervised rehabilitation following anterior cruciate ligament reconstruction: a randomized controlled trial

    J Orthop Sports Phys Ther

    (1998)
  • D.J Beard et al.

    Proprioception enhancement for anterior cruciate ligament deficiency. A prospective randomised trial of two physiotherapy regimes

    J Bone Joint Surg Br

    (1994)
  • D.J Beard et al.

    Reflex hamstring contraction latency in anterior cruciate ligament deficiency

    J Orthop Res

    (1994)
  • M Berchuck et al.

    Gait adaptations by patients who have a deficient anterior cruciate ligament

    J Bone Joint Surg [Am]

    (1990)
  • B.D Beynnon et al.

    The effect of anterior cruciate ligament trauma and bracing on knee proprioception

    Am J Sports Med

    (1999)
  • P.A Borsa et al.

    The effects of joint position and direction of joint motion on proprioceptive sensibility in anterior cruciate ligament-deficient athletes

    Am J Sports Med

    (1997)
  • E.B Bynum et al.

    Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study.

    Am J Sports Med

    (1995)
  • N.D Carter et al.

    Joint position sense and rehabilitation in the anterior cruciate ligament deficient knee

    Br J Sports Med

    (1997)
  • J.P Corrigan et al.

    Proprioception in the cruciate deficient knee

    J Bone Joint Surg [Br]

    (1992)
  • M.S DeCarlo et al.

    Traditional versus accelerated rehabilitation following ACL reconstruction: A one-year follow-up

    J Orthop Sports Phys Ther

    (1992)
  • P DeVita et al.

    Gait biomechanics are not normal after anterior cruciate ligament reconstruction and accelerated rehabilitation

    Med Sci Sports Exerc

    (1998)
  • R.P Di Fabio et al.

    Effect of knee joint laxity on long-loop postural reflexes: evidence for a human capsular-hamstring reflex

    Exp Brain Res

    (1992)
  • L.F Draganich et al.

    Coactivation of the hamstrings and quadriceps during extension of the knee

    J Bone Joint Surg [Am]

    (1989)
  • S.F Dye

    The knee as a biologic transmission with an envelope of function: a theory

    Clin Orthop

    (1996)
  • S.F Dye et al.

    Factors contributing to function of the knee joint after injury or reconstruction of the anterior cruciate ligament

    Instr Course Lect

    (1999)
  • M.E Eastlack et al.

    Laxity, instability, and functional outcome after ACL injury: copers versus noncopers

    Med Sci Sports Exerc

    (1999)
  • L.G Elmqvist et al.

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

    Eur J Appl Physiol

    (1988)
  • G.P Ernst et al.

    Lower extremity compensations following anterior cruciate ligament reconstruction

    Phys Ther

    (2000)
  • T Fischer-Rasmussen et al.

    Proprioceptive sensitivity and performance in anterior cruciate ligament-deficient knee joints

    Scand J Med Sci Sports

    (2000)
  • G.K Fitzgerald

    Open versus closed kinetic chain exercise: issues in rehabilitation after anterior cruciate ligament reconstructive surgery

    Phys Ther

    (1997)
  • G.K Fitzgerald et al.

    The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals

    Phys Ther

    (2000)
  • T Fridén et al.

    Review of knee proprioception and the relation to extremity function after an anterior cruciate ligament rupture

    J Orthop Sports Phys Ther

    (2001)
  • T Fridén et al.

    Function after anterior cruciate ligament injuries. Influence of visual control and proprioception

    Acta Orthop Scand

    (1998)
  • T Fridén et al.

    Proprioceptive defects after an anterior cruciate ligament rupture — the relation to associated anatomical lesions and subjective knee function

    Knee Surg Sports Traumatol Arthrosc

    (1999)
  • T Fridén et al.

    Proprioception in the nearly extended knee. Measurements of position and movement in healthy individuals and in symptomatic anterior cruciate ligament injured patients

    Knee Surg Sports Traumatol Arthrosc

    (1996)
  • T Fridén et al.

    Proprioception after an acute knee ligament injury: a longitudinal study on 16 consecutive patients

    J Orthop Res

    (1997)
  • T Fridén et al.

    Anterior-cruciate-insufficient knees treated with physiotherapy. A three-year follow-up study of patients with late diagnosis

    Clin Orthop

    (1991)
  • H Gauffin et al.

    Function testing in patients with old rupture of the anterior cruciate ligament

    Int J Sports Med

    (1990)
  • H Gauffin et al.

    Altered movement and muscular-activation patterns during the one-legged jump in patients with an old anterior cruciate ligament rupture

    Am J Sports Med

    (1992)
  • A Harilainen et al.

    Good muscle performance does not compensate instability symptoms in chronic anterior cruciate ligament deficiency

    Knee Surg Sports Traumatol Arthrosc

    (1995)
  • Henriksson (Lysholm) M. Rehabilitation and evaluation after anterior cruciate ligament injury. Function, stability and...
  • M Henriksson et al.

    Postural control after anterior cruciate ligament reconstruction and functional rehabilitation

    Am J Sports Med

    (2001)
  • M Hoffman et al.

    An investigation of postural control in postoperative anterior cruciate ligament reconstruction patients

    J Athl Train

    (1999)
  • L.J Huston et al.

    Neuromuscular performance characteristics in elite female athletes

    Am J Sports Med

    (1996)
  • H Johansson et al.

    Receptors in the knee joint ligaments and their role in the biomechanics of the joint

    Crit Rev Biomed Eng

    (1991)
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    Eva Ageberg graduated from Lund University, Sweden in 1992. From 1994 she has worked at the Physical Medicine Unit, Department of Rehabilitation, Lund University Hospital. She has specialized in Physiotherapy in Orthopedics, and received her MSc in Physical Therapy in 1998. Her postgraduate studies at the Institute for Musculoskeletal Diseases, Department of Physical Therapy, Lund University, involve assessment of neuromuscular function, mainly postural control, and effects of rehabilitation in individuals with anterior cruciate ligament injury in the knee.

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