Controversies Between Open
and Closed Chain Exercises after
ACL Reconstruction
Megan Bechtold, DPT, OCS,
CMPT
Objectives
1. Understand historical perspectives that led to
the era of open kinetic chain (OKC) avoidance
in the presence of anterior cruciate ligament
reconstruction (ACLR)
2. Discuss current literature and how this supports
or refutes the avoidance of OKC exercise
3. Discuss evidence-supported recommendations
for exercise prescription after ACLR
Take a poll
Benefits to Closed Kinetic Chain
(CKC) Exercise after ACLR
• Reduce the anteriordirected forces that act
on the tibia
• Increase tibiofemoral
compressive forces
• Increase cocontraction
of the hamstrings
• Mimic functional
activities
• Less patellofemoral
symptoms
A: No OKC
• Avoidance of open kinetic chain (OKC) exercise
altogether
B: Partial OKC
• Marginal incorporation of OKC and/or delayed
incorporation of OKC exercise
C: Full OKC
• Immediate and consistent use of OKC exercise
throughout rehab
Historical Perspective
1970s-1980s
• “Gold Standard”
– BPTB grafts with improving fixation and
consistently good outcomes
– Prolonged immobilization
– Open chain quad exercises
(Davarinos, 2014)
1980s-early 90s
• Studies determine that the lower leg, when
acted upon by the quadriceps femoris, is
pulled anteriorly relative to the femur
– 86% of that load is restrained by the ACL
(Butler,; 1980; Herzog, 1993; Kaufman, 1991; Wilk, 1996 )
Henning et al, 1985
• In vivo study using arthroscopy with strain
gage
• Significantly less ACL strain with a partial
squat than with a straight leg raise with
20#.
“We recommend that quadriceps exercises and testing
by knee extension through a full range of motion not be
done during the first year following ACL injury or
reconstruction.”
Bynum et al, 1995
• Prospective, randomized study
• Aim: to determine if closed kinetic chain
exercise is “safe” and if it “offers any
advantages”
“As a result of this study, we now use the closed
kinetic chain protocol exclusively after anterior
cruciate ligament reconstruction.”
Mikkelsen et al., 2000
• Prospective, matched follow-up study
• Aim: to determine if CKC only versus CKC plus
OKC training generates better outcomes after
ACL reconstruction
“…the addition of OKC quadriceps training after ACL
reconstruction results in a significantly better
improvement in quadriceps torque without reducing
knee joint stability at 6 months and also leads to a
significantly higher number of athletes returning to their
previous activity earlier…”
+
Perry et al., 2005
• Randomized, single-blind clinical trial
• Aim: to determine the effect of OKC vs CKC
exercise on laxity and knee function in the ACL
reconstructed knee
“OKC and CKC knee extensor training in the
middle period of rehabilitation after ACLR surgery
do not differ in their effects on knee laxity or leg
function.”
Does OKC pose a threat to the
reconstructed ACL?
Does OKC offer advantages to
outcomes after ACL
reconstruction?
Literature Update:
Does OKC loading pose a
threat to the ACLreconstructed knee?
Heijne et al., 2007
• Prospective randomized outcome study
• Early OKC exercise with hamstring graft
led to increased anterior laxity
“…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 [of OKC] after bone-patellar tendon-bone
ACL reconstruction.”
Morrissey et al., 2009
• Aim: To determine which, if any, training
factors are related to changes in anterior
laxity scores after ACL injury or
reconstruction.
“These results offer some early clinical support for
increasing the strain on the anterior cruciate
ligament graft…during rehab to promote decreased
knee laxity.”
Barcellona et al., 2013
• Randomized controlled trial
• Decreased anterior laxity with high-load
OKC exercise in ACLI patients
“…open kinetic chain resistance training at loads of
2 sets of 20RM led to a reduction in anterior knee
laxity in the ACLI knee.”
Yes for OKC
No for OKC
Literature Update:
Does OKC exercise
improve outcomes?
Tagesson et al., 2008
• Randomized clinical trial
• Greater quadriceps strength was attained
with OKC vs CKC exercise
“Rehab with OKC quadriceps exercise led to
significantly greater quadriceps strength
compared with rehab with CKC quadriceps
exercise…Patients with ACL deficiency may need
OKC quadriceps strengthening to regain good
muscle torque.”
Beynnon et al., 2011
• Prospective, randomized, double-blind
study
• No diff between OKC and CKC in long
term outcome or laxity
“Rehab with either accelerated or nonaccelerated
programs after ACL reconstruction with a bonepatellar tendon-bone autograft produces the
same effect on clinical outcome, patient
satisfaction, patient function and proprioception.”
Fukuda et al., 2013
• Randomized, controlled clinical trial
• No difference in early vs late initiation of
OKC exercise
“Early open kinetic chain group reached the
same findings in relation to pain decrease and
functional improvement when compared with the
late open kinetic chain group but showed a
faster recovery in quadriceps strength.”
Yes for OKC
No for OKC
Systematic Reviews
Andersson et al., 2009
• 70 articles reviewed
“CKC produced less pain and
laxity while promoting better
subjective outcome than OKC
after BPTB reconstruction.”
Glass et al., 2010
• 6 articles reviewed
• “CKC exercises alone were not found by
any studies to be superior to OKC
exercises.”
“…favorable results for utilization of both open and
closed kinetic chain exercises for intervention with
ACL deficient or reconstructed knees.”
Lobb et al., 2012
• 5 systematic reviews were reviewed
“There was moderate evidence of equal
effectiveness of closed versus open kinetic
chain exercise…”
And the winner is…
Yes for OKC
No for OKC
Recommendations
Recommendations
• Further research
• Consider the graft type, healing time and
patellofemoral loading principles when
implementing exercise after ACLR
• If implementing OKC exercise, consider
incorporating a conscious hamstring cocontraction (Biscarini, 2014)
• Incorporate closed-chain eccentrics in the
early phases of rehab to maximize strength
potential (Gerber, 2007)
Thank you!
References
Biscarini A, Benvenuti P, Botti FM, Brunetti A, Brunetti O, Pettorossi VE. Voluntary
Enhanced Cocontraction of Hamstring Muscles During Open Kinetic Chain Leg Extension
Exercise: Its Potential Unloading Effect on the Anterior Cruciate Ligament. Am J Sports
Med. 2014; 42: 2103-2112.
Heijne A, Werner S. Early versus late start of open kinetic chain quadriceps exercises
after ACL reconstruction with patellar tendon or hamstring grafts: a prospective
randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007; 15: 402-414.
Barcellona MG, Morrissey MC, Milligan P, Clinton M, Amis AA. The effect of knee
extensor open kinetic chain resistance training in the ACL-injured knee. Knee Surg
Sports Traumatol Arthrosc. 2014. doi: 10.1007/s00167-014-3110-6.
Fukuda TY, Fingerhut D, Moreira VC, et al. Open Kinetic Chain Exercises in a Restricted
Range of Motion After Anterior Cruciate Ligament Reconstruction: A Randomized
Controlled Clinical Trial. Am J Sports Med. 2013;41:788-794.
Glass R, Waddell J, Hoogenboom B. The Effects of Open versus Closed Kinetic Chain
Exercises on Patients With ACL Deficient or Reconstructed Knees: A Systematic Review.
North American Journal of Sports Physical Therapy. 2010;5:74-83.
Lobb R, Tumilty S, Claydon LS. A review of systematic reviews on anterior cruciate
ligament reconstruction rehabilitation. Physical Therapy in Sport. 2012;13:270-278.
Nyland J, Brand E, Fisher B. Update on rehabilitation following ACL reconstruction. Open
Access Journal of Sports Medicine. 2010;1:151-156.
References
Grodski M, Marks R. Exercises Following Anterior Cruciate Ligament Reconstructive
Surgery: Biomechanical Considerations and Efficacy of Current Approaches. Research
in Sports Medicine: An International Journal. 2008;16:75-96.
Tagesson S, Oberg B, Good L, Kvist J. A comprehensive rehabilitation program with
quadriceps strengthening in closed versus open kinetic chain exercise in patients with
anterior cruciate ligament deficiency: a randomized clinical trial evaluating dynamic tibial
translation and muscle function. 2008;36:298-307.
Cooper RL, Taylor NF, Feller JA. A systematic review of the effect of proprioceptive and
balance exercises on people with an injured or reconstructed anterior cruciate ligament.
Research in Sports Medicine: An International Journal. 2005;13(2):163-178.
Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior cruciate ligament
tears in children and adolescents: A meta-analysis of nonoperative versus operative
management. 2014;42:2769-2776.
Andersson D, Samuelsson K, Karlsson J. Treatment of anterior cruciate ligament injuries
with special reference to surgical technique and rehabilitation: an assessment of
randomized controlled trials. 2009;25(6):653-685.
Beynnon BD, Johnson RJ, Naud S, et al. Accelerated versus nonaccelerated
rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized,
double-blind investigation evaluating knee joint laxity using roentgen
stereophotogrammetric analysis. 2011;39:2536-2548.
Davaromos N, Oneill BJ, Curtin W. A brief history of anterior cruciate ligament reconstruction.
Advances in Orthopedic Surgery. 2014;2014:1-6.
References
Beynnon BD, Fleming BC. Anterior cruciate ligament strain in-vivo: a review of previous
work. J Biomech. 1998;31:519-525.
Butler DL, Noyes FR, Grood ES, Ligamentous restraints to anterior-posterior drawer in
the human knee: a biomechanical study. J Bone Joint Surg Am. 1980;62:259-270.
Herzog W, Read LJ. Lines of action and moment arms of the major force-carrying
structures crossing the human knee joint. J Anat. 1993;182(pt 2):213-230.
Kaufman KR, An KN, Litchy WJ, Morrey BF, Chao EY. Dynamic joint forces during knee
isokinetic exercise. Am J Sports Med. 1991;19:305-316.
Wilk KE Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR, Boyd ML. A comparison
of tibiofemoral joint forces and electromyographic activity during open and closed kinetic
chain exercises. Am J Sports Med. 1996;24:518-527.
Bynum EB, Barrack RL, Alexander AH. Open versus closed chain kinetic exercises after
anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports
Med. 1995;23(4):401-406.
Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined
open and closed kinetic chain exercises for quadriceps strengthening after anterior
cruciate ligament reconstruction with respect to return to sports: a prospective matched
follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8:337-342.
Morrissey MC, Perry MC, King JB. Is knee laxity change after ACL injury and surgery
related to open kinetic chain knee extensor training load? Am J Phys Med Rehab.
2009;88(5):369-375.
References
Perry MC, Morrissey MC, King JB, Morrissey D, Earnshaw P. Effects of closed versus
open kinetic chain knee extensor resistance training on knee laxity and leg function in
patients during the 8- to 14-week post-operative period after anterior cruciate ligament
reconstruction. Knee Surgery Sports Traumatology Arthroscopy. 2006;13(5):357-369.
Henning CE, Lynch MA, Glick KR: An in vivo strain gage study of elongation of the
anterior cruciate ligament. Am J Sports Med. 1985;13:22-26.
Biscarini et al., 2014
• Descriptive lab study
• Hamstring co-contraction decreases
anterior shear and may have rehabilitation
implications when utilizing OKC exercise
“…intentional hamstring cocontraction may have the
potential to be a safe and effective quadricepsstrengthening intervention in the early stages of
rehabilitation…”