Prevention of knee stiffness following ligament reconstruction: Understanding the role of Arthrogenic Muscle Inhibition (AMI)

Abstract

The knee is a joint that is often injured in sport, with a large and increasing number of ligament tears and repairs; postoperative complications can lead to poor outcome, such as stiffness. Beyond the well-known and well-described intra- and extra-articular causes of postoperative stiffness, the present study introduces the concept of a central reflex motor inhibition mechanism called arthrogenic muscle inhibition (AMI). AMI occurs after trauma and can be defined as active knee extension deficit due to central impairment of Vastus Medialis Obliquus (VMO) contraction, often associated with spinal reflex hamstring contracture. This explains the post-traumatic flexion contracture that is so common after knee sprain. The clinical presentation of AMI is easy to detect in consultation, in 4 grades from simple VMO inhibition to fixed flexion contracture by posterior capsule retraction in chronic cases. After recent anterior cruciate ligament (ACL) tear, more than 55% of patients show AMI, reducible in 80% of cases by simple targeted exercises initiated in consultation. Practically, in patients who have sustained knee sprain, it is essential to screen for this reflex mechanism and assess reducibility, as AMI greatly aggravates the risk of postoperative stiffness. In case of hemarthrosis, we recommend joint aspiration, which provides immediate benefit in terms of pain and motor inhibition. In case of persistent AMI, classical electrostimulation and "cushion crush", as used by all physiotherapists, are ineffective. To reduce the risk of postoperative stiffness, no surgery should be considered until AMI has resolved. LEVEL OF EVIDENCE: expert opinion.

Keywords: Anterior cruciate ligament; Arthrogenic muscle inhibition; Knee sprain; Postoperative stiffness; Restricted motion.