In other words, when it comes to OKC following ACLR, you can do … I’d say let’s probably still start at 90 to 40 and gradually add some linear load to that because we know at least it won’t put that much strain on the graft. Lenny Macrina: The full range of motion, full active. So here’s how I envision it right now. 2009 May;88(5):369-75. Clinical studies suggest that both play a beneficial role in the early rehabilitation of the reconstructed knee. Awesome. This blog (research review) is an example of what our review service looks like. Lenny Macrina: Again more so I see a lot of patellar tendon grafts, I will go a little slower in general with a hamstring graft because of the soft tissue fixation, but with the patellar tendon graft to bone and bone I’m definitely more aggressive in how I treat those people post op. What’s the benefit? Think about that for a second. Who knows, maybe we’re wrong? I think we think the graft tears at about 15 to 20% strain on it or the ACL tears at about 15 20%. Mike Reinold: The things they’re going to do around the house and in their daily lives is going to strain the graft a little bit. So they said, let’s stop. Dr Teddy Willsey has just done a Masterclass lecture series for us! Here’s our approach to combining technique plus strength and power development to maximize speed in our athletes. You talked about motion, but what’s the strain? Am J Phys Med Rehabil. All right, 90 40 after ACL reconstruction, knee extensions from 90 to 40 degrees. This is simply not true, with commonly used closed kinetic chain exercises straining the ACL as much as knee extensions. The secondary objectives were to see if there were any differences in strength, function, quality of life and adverse events when comparing the 2 types of exercises. I would suggest: mini-squats 0 – 30, Open chain weighted quad extensions from 90 – 45 degrees, and closed chain step exercises in the early rehab. We often focus on preventing a loss of extension ROM after ACL surgery, but what about flexion? Mike Reinold: Close but you know what my guess is? But again that research is still-. There’s a lot to explore here! Sixty-eight patients, 36 males and 32 females, with either patellar tendon graft (34 patients) or … Hopefully we can get them on a future episode. Enjoy! Goals for Phase 1 of the Post-operative Functional ACL Reconstruction Rehab program include restoration of ROM and mobility, management of pain and edema, and initiation of strengthening with emphasis on the quadriceps. So with that, because I’ve seen that, I tend to do it sooner than the 12 weeks because I don’t think that magically at 12 weeks things are anymore somewhat healed than at six weeks. It’s open chain versus closed chain. On this episode of the #AskMikeReinold show we talk about whether or not we perform knee extension exercises in the open kinetic chain after ACL reconstruction, and if we still limit them from 90 to 40 degrees of flexion. Get exclusive learning material for free. Mike Reinold: So we’re quite sub-threshold on that. Avoid pain with … Recent biomechanical studies have shown that the peak strains produced on a graft are similar. For example, a standing squat is a closed-chain exercise, because the feet are on the floor, whereas a seated quadriceps extension is an open-chain exercise because the lower leg is free to move. But when you look at the hordes of research on ACL reconstruction, you can absolutely safely and effectively use knee extensions with this patient population. That makes sense? Weeks 13-26. (1) The peak anterior shear force during a seated leg extension from 0-90 degrees of knee flexion was found to be 248N at 14 degrees of knee flexion. Although the authors of this paper have still urged caution with the use of OKC exercises in the first 12 weeks post-op, it has highlighted the simple fact that OKC exercises can be used without fear of stretching the ACL graft and subsequent graft failure from 12 weeks post-op – at the very least. I don’t think we need to pick an exercise that’s also going to strain it at this point. Lenny Macrina: The strain that I’ve seen in some of the studies that are out there, and ischemia has a nice review, I think that was JOSPT 2012 that he basically captured all the literature at that time. From the study: OBJECTIVE: The purpose of this study was to evaluate whether knee anterior laxity changes after anterior… s should be the intervention of choice following an anterior cruciate ligament (ACL) injury or reconstruction Knee joint in open kinetic chain extension exercises 57 howe ver , decreased with joint flexion angle under both loading conditions, though the reduction was greater Post Op Care of ACL Reconstructions. It was dramatic, I felt some suspense with that. And I think that’s the question that came up. Noehren and Snyder-Mackler, entitled “Who’s Afraid of the Big Bad Wolf? So we still have people to mini squats. Should we change these things? Open-chain exercises are safe to perform after an ACL injury or ACL reconstruction. Seven electronic databases were searched, looking for randomised controlled trials (RCTs) comparing OKC vs CKC exercises following ACLR up until to April 2017. Open-kinetic chain (OKC) and closed-kinetic chain (CKC) exercises may not differ in their effects on the healing response of the anterior cruciate ligament (ACL)-reconstructed knee. I don’t know if we know the answer. But then once you get down the road a little bit, you start opening the window. There is thought that the tibia does translate anteriorly a little bit more in the last degrees range of motion from 40 to zero. It’s almost four months before you start getting real aggressive on that. Mike Reinold: So I think bio mechanically again where this started was the Bennion Fleming studies, they obviously had a lot of strain gauge type research that showed some strain with comparatively open kinetic chain versus closed kinetic chain, that’s where this all started. You can use the player below to listen to the podcast or subscribe. Many therapists and surgeons refuse to use resisted open-kinetic chain (OKC) knee extensions with patients who have undergone ACL reconstruction (ACLR) for fear of tearing the ACL/increasing laxity. Knee Extension – Using a rolled towel under the foot so back of the client’s leg is off of the bed, then squeeze the knee down into the bed. Experts disagree about the safety of this type of exercise. Furthermore, the early introduction of OKC exercises for quadriceps did not influence … THANKS! Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about knee extension strengthening exercises after ACL reconstruction, and really about that whole 90/40 concept. The often-stated reason for avoiding such as exercises is that it will stretch and damage the surgical graft. - Effect on knee stability if full hyperextension is restored immediately after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction. Restoring quadriceps muscle strength is integral to recovery following an anterior cruciate ligament reconstruction. Lenny Macrina: I get your Tommy boy reference. That a good answer maybe? Not that I’m doing KT test on people, I haven’t seen the issues that we think could potentially happen. And what they showed was closed chain just didn’t have that anterior stress, that strain I should say, it didn’t have it, and open chain at terminal knee extension did. That’s fine. So if you want to go up a little bit I think you probably could, but I think you just got to be careful loading it in that position. Head to mikereinold.com, click on that podcast link and you can ask us more questions like that. Does walking on flat ground, climbing stairs and cycling strain the ACL? Subscribe: Apple Podcasts | Google Podcasts | Spotify | RSS | More. Using knee extensions after acl reconstruction can be done safely Initially, recommend modifying the range to 90-40 and put pad at mid-shin Don’t recommend starting knee extensions until at least 4 weeks post-op You cannot isolate the quad with CKC exercises only The ACL also prevents posterior translation of the femur on the tibia in closed-kinetic chain. Getting the knee actively into extension is an important goal in the first few days/weeks following ACL reconstruction. Patella grafts were found to be less vulnerable to the early introduction of OKC exercises, despite the differences in exercise protocols between the 3 trials reviewed. They literally put strain gauges in healthy people in their ACL while they were doing exercises. The primary objective of this review was to see if OKC exercises resulted in increased tibial laxity at short term (<3 months), medium term (3-6 months), long term (6-12 months) and very long term (12+ months) when compared to closed kinetic chain (CKC) exercises. Should we Still be Using Rehabilitation Protocols? Get the motion back, like you said, especially extension and then really be able to focus on those last three months of rehab when the strength gains going to be huge and required in the functional aspect of returning. Study methodological quality was assessed using the GRADE approach. Recent studies have shown that an early start of open kinetic chain (OKC) exercises for quadriceps strengthening in a full range of motion (ROM) could increase anterior knee laxity after anterior cruciate ligament (ACL) reconstruction with flexor tendons. More sports medicine and physical rehabilitation professionals will embrace the use of OKC exercises once they learn about the research supporting its use. My advice: 3x15-20reps (holding each rep for 3-5seconds), 2-3x per day in the … So what’s the percentage strain to tear the graft? I do know that a lot of well-respected people probably still follow those guidelines a little bit. In the case of an ACL injury, this is the foot. Mike Reinold: Hi Joe, what do we got for a question today? Limited evidence from 3 studies (n=116) showing no significant differences between groups at any time point for single leg hop and triple crossover hop regardless of when OKC exercise were introduced, One reported 2 graft failures in early OKC group, One study reported 2 graft failures in each group, The other study was not clear in which group the adverse events occurred, Fukuda used supervised OKC exercises at 4 weeks post-op restricted in ROM from 45-90deg knee flexion until the 12-week post-op mark. So I don’t think this or this exercise is that important. However, there are no clinical trials that evaluated outcomes of OKC exercises in a restricted ROM for pain, function, … That’s an important part. Beynnon et al. I think the answer is you probably could go all the way to extension, but you certainly probably don’t want to do that with a ton of weight. One must also be critical of the laxity found in this trial, with the average laxity between groups in the Heijne study being 1.4mm, which is within the clinically meaningful threshold of 2mm associated with increased ACLR graft rupture. This inconsistency may be explained however by their use of different protocols within each study; The increased ACL laxity shown in Heinje study may be explained by basic science research showing that ACL strain is 0% when OKC quad contractions are performed at 60-90deg of knee flexion and reaches its peak strain between 0-30deg of knee extension. So that’s a little bit about the history of that a little bit of where it came from and I don’t know if we know the answers right away, but I definitely think there’s some workarounds that will get the strength back, that will still make sure that they have terminal knee extension but not put that little bit of strain just in case. But again, if you look at some of those Bennion studies in the strain gauge, some of the curves, the strain on the ACL in full do an open chain active range of motion, even weighted, is very similar to doing a closed chain mini squat. tled “Who’s Afraid of the Big Bad Wolf? By continuing to use this site you accept the use of cookies in accordance with, High vs Low Intensity Strength Training for Knee Osteoarthritis, The Power of Education for Managing Patellofemoral Pain. I do it I just do it a little earlier than I used to. Anything you guys want to talk about. To determine whether a trial should be included, trials were reviewed using predetermined criteria. In regards to tibial laxity, the established cut-off for clinical laxity is >2mm compared to the opposite side. Yes. Yes. Then make sure that you can contract the quad with your knee fully extended. But then I think the real question comes down to is, when do you let them get after it in a knee extension machine down the road. The study was also required to involve rehabilitation methods and protocols following ACLR surgery… Heijne et al started OKC at 4 weeks, but progressed to full knee extension at 6 weeks post-op. Imagine that if you got a freaking needle in your knee and you have to do an exercise. So it’s interesting studies. So I think the science is changing our opinion a little bit here. Here is a very simple exercise option, and can be grouped together quite nicely with "prone knee hangs" (which encourages the knee into passive knee extension). The Power of Education for Managing Patellofemor... Low to moderate quality evidence from 3 studies (n=203) with no between group differences in laxity at any time points from the early addition of OKC when compared to CKC, Limited evidence from 2 studies (n=93) showing no difference between groups in laxity at medium and long-term follow ups when adding OKC exercises later in rehab, Low-moderate quality evidence from 2 studies (n=113) showing no between group differences in strength at any time point. In conclusion, early start of OKC quadriceps exercises after hamstring ACL reconstruction resulted in significantly increased anterior knee laxity in comparison with both late start and with early and late start after bone-patellar tendon-bone ACL reconstruction. Lenny Macrina: If you look at a study that came out, I forget what it was, a few years ago, it was an MRI study looking at the strain on the ACL. Of the 10 studies included in this review, they analysed 494 participants with a mean age range of 19-34yrs (74% males). Len, historically why don’t you tell us a little bit about maybe the origin of that? Morrissey MC, Perry MC, King JB. During seated knee extension, ACL force decreases when the resistance pad is positioned more proximal on the anterior aspect of the lower leg, away from the ankle. A mountain of new information supports the safe use of open-kinetic chain (OKC) knee extensions after ACL reconstruction (ACLR). Ankle Mobility Drills to Improve Dorsiflexion, PLEASE click here to leave us a review in iTunes, http://media.blubrry.com/askmikereinold/p/traffic.libsyn.com/askmikereinold/199_Knee_Extension_Strengthening_Exercises_After_ACL_Reconstruction.mp3, ACL Reconstruction Rehabilitation Protocol, How to Periodize Strength Training After ACL Surgery, Loss of Flexion Range of Motion after ACL Reconstruction.
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