Anterior Cruciate Ligament (ACL) Rehabilitation

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Search Strategy

Search engines: PubMed, Pedro
Key words: anterior cruciate ligament, Open chain exercises, Closed chain exercises, ACL rehabilitation,…

Definition/Description

ACL rehabilitation has undergone considerable changes over the past decade. Intensive research into the biomechanics of the injured and the operated knee have led to a movement away from the techniques of the early 1980's characterized by post operative casting, delayed weight bearing and limitation of ROM, to the current early rehabilitation program with immediate training of ROM and weight bearing exercises[1] (Level A).

The major goals of rehabilitation of the ACL-injured knee:

• Gain good functional stability
• Repair muscle strength
• Reach the best possible functional level
• Decrease the risk for re-injury

Closed kinetic chain exercises (CKC) and Open kinetic chain exercises (OKC) play an important role in regaining muscle (quadriceps, hamstrings) strength and knee stability.

Closed kinetic chain exercises  have become more popular than Open kinetic chain exercises in ACL rehabilitation. Clinicians believe that CKC exercises are safer than OKC exercises because they place less strain on the ACL graft. Besides, they also believe that CKC exercises are more functional and equally effective as OKC exercises[3] (Level A).

Clinically Relevant Anatomy

add text here

Epidemiology /Etiology

add text here

Characteristics/Clinical Presentation

add text here

Differential Diagnosis

add text here

Diagnostic Procedures

add text here related to medical diagnostic procedures

Outcome Measures

add links to outcome measures here (also see Outcome Measures Database)

Examination

add text here related to physical examination and assessment

Medical Management

add text here

 Physical Therapy Management

 

1. Open-Kinetic-Chain exercises:

1.1. Characteristics

 - Non-weight bearing

-  Movement occurring at a single joint

-  Distal segment free to move

-  Resistance is usually applied to the distal segment

1.2. Open-Kinetic-Chain Knee-Extension exercises

These exercises have a limited role in ACL rehabilitation programs, because research showed that OKC-extension exercises from 60° to 0° flexion, markedly increase anterior tibial translation in the ACL-deficient knee, as well as ACL graft strain in the reconstructed knee^[2](Level 2B).

Despite these findings, OKC-extension exercises aren’t excluded in ACL-rehabilitation programs, because the same research has shown that OKC-extension exercises from 90° to 60° of flexion could be done safe, without increasing anterior tibial translation or ACL graft strain^[2] (Level 2B).

In short, OKC-extension exercises in ACL rehabilitation programs could be done safe in a ROM from 90° to 60° flexion and are furthermore useful to train the quadriceps isolated.

1.3. Open-Kinetic-Chain Knee-Flexion exercises

OKC-flexion exercises play an important part in the rehabilitation process because research showed that there is no anterior tibial translation or ACL graft strain during these exercises. Besides, they result in isolated hamstrings muscle contraction^[10] ( Level 2B).

2. Closed-Kinetic-Chain Knee exercises:

2.1. Characteristics

- Weight bearing
- Movement at several joints
- Distal segment fixed to a surface
- Resistance may be applied both proximally and distally

2.2. Closed-Kinetic-Chain Knee exercises

CKC-exercises play an important role in ACL-rehabilitation because they result in a hamstrings-quadriceps co-contraction that reduces tibiofemoral shear forces. Besides, research showed that during CKC-exercises body weight provides tibiofemorale joint compression, that also reduces tibiofemoral shear forces ^[7] (Level A).

CKC exercises have several advantages compared with OKC exercises^[12] (Level F).

• Increase stability in the knee joint (more joint compression)
• Functional load
• Strong coordinative training
• Minimal shear force
• Less stress on the ACL
• No selective muscle training
• Weakest link in the chain is feeling the most "overload" and the corresponding largest trainings effect
• Fewer complications such as patellofemoral symptoms
• CKC-exercises are earlier to apply than OKC-exercises

3. Examples

3.1. Postoperative phase 1 ( 1-5 weeks)

• Exercises 1:

The first CKC-exercises are sitting exercises because they facilitate flexion and extension movements in the knee [9] (Level A).

The patient lying on a table has to extend the knee against resistance from a stretcher.

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Clinical Bottom Line

add text here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.

,