Summary
Rehabilitation is recognised as a critical component in the treatment of the anterior cruciate ligament (ACL) injured athlete, and has been the subject of intense research over the past decade. As a result, sound scientific principles have been applied to this realm of sports medicine, and have improved the outcome of both surgical and nonsurgical treatment. Possibly the most intriguing of these principles is the use of the kinetic chain concept in exercise prescription following ACL reconstruction.
The hip, knee, and ankle joints when taken together, comprise the lower extremity kinetic chain. Kinetic chain exercises like the squat recruit all 3 links in unison while exercises such as seated quadriceps extensions isolate one link of the chain. Biomechanical assessment with force diagrams reveals that ACL strain is reduced during kinetic chain exercise by virtue of the axial orientation of the applied load and muscular co-contraction.
Additionally, kinetic chain exercise through recruitment of all hip, knee, and ankle extensors in synchrony takes advantage of specificity of training principles. More importantly, however, it is the only way to reproduce the concurrent shift of ‘antagonistic’ biarticular muscle groups that occurs during simultaneous hip, knee, and ankle extension. Incoordination of the concurrent shift fostered by exercising each muscle group in isolation may ultimately hamper complete recovery. Modifying present day leg press and isokinetic equipment will allow clinicians to make better use of kinetic chain exercise and allow safe isokinetic testing of the ACL reconstructed knee. Reconstruction of the ACL with a strong well placed graft to restore joint kinematics, followed by scientifically sound rehabilitation to improve dynamic control of tibial translation, will improve the outcome after ACL injury.
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References
Anderson AF, Lipscomb AB. Analysis of rehabilitation techniques after anterior cruciate reconstruction. American Journal of Sports Medicine 17(2): 154–160, 1989.
Arms SW, Pope MH, Johnson RJ, et al. The biomechanics of anterior cruciate rehabilitation and reconstruction. American Journal of Sports Medicine 12(1): 8–18, 1984.
Atha J. Strengthening muscle. Exercise and Sports Science Reviews 9: 1–73, 1981.
Balkfors B. The course of knee ligament injuries. Acta Orthopaedica Scandinavica 53(Suppl. 198): 179, 1982.
Baratta R, Solomonow M, Zhou BH, et al. Muscular coactivation: the role of the antagonist musculature in maintaining knee stability. American Journal of Sports Medicine 16(2): 113–122, 1988.
Bourne MH, Hazel WA, Scott SG, et al. Anterior knee pain. Mayo Clinic Proceedings 63(42): 491, 1988.
Butler DL, Noyes FR, Grood ES. Ligamentous restraints to anterior-posterior drawer in the human knee: a biomechanical study. Journal of Bone and Joint Surgery 62-A: 259–270, 1980.
Chick RR, Jackson DW. Tears of the anterior cruciate ligament in young athletes. Journal of Bone and Joint Surgery 60-A: 970–973, 1978.
Clancey WG, Nelson DA, Reider B, et al. Anterior cruciate ligament reconstruction using one-third of the patellar tendon ligament augmented by extra-articular tendon transfers. Journal of Bone and Joint Surgery 64-A(3): 352–359, 1982.
Clancey WG, Ray JM, Zolten PJ. Acute tears of the anterior cruciate ligament — surgical vs. conservative treatment. Journal of Bone and Joint Surgery 70-A(10): 1483–1388, 1988.
DePalma BF, Zelko RR. Knee rehabilitation after anterior cruciate ligament injury or surgery. Athl Training, Fall 1986.
Dons B, Bollerup K, Bonde-Petersen F, et al. The effect of weightlifting exercise related to muscle fibre composition and muscle cross-sectional area in humans. European Journal of Applied Physiology 40: 95–106, 1979.
Draganich LF, Jaeger RJ, Knalj AR. Coactivation of the hamstrings and quadriceps during extension of the knee. Journal of Bone and Joint Surgery 71-A(7): 1075–1080, 1989.
Fahey TD. Physiologic adaptation to conditioning. In Fahey TD (Ed.) Athletic training: principles and practice, pp. 57–78, May-field Publishing, Palo Alto, CA, 1986.
Fahey TD, Brown CH. The effects of an anabolic steroid on the strength, body composition and endurance of college males when accompanied by a weight training program. Medicine and Science in Sports 5: 272–276, 1973.
Fetto JF, Marshall JL. The natural history and diagnosis of anterior cruciate ligament insufficiency. Clinical Orthopedics 147: 29–38, 1980.
Gerber C, Matter P. Biomechanical analysis of the knee after rupture of the anterior cruciate ligament and its primary repair: an instant-centre analysis of function. Journal of Bone and Joint Surgery 65: 391, 1983.
Giove T, Miller S, Kent B, et al. Nonoperative treatment of the torn anterior cruciate ligament. Journal of Bone and Joint Surgery 65-A (2): 184–192, 1983.
Gollanick PD, Erickson E, Harmark T, et al. Rehabilitation of the knee following surgery. Medicine and Science in Sports 8: 133–134, 1976.
Gowitzke BA, Millner S. Scientific bases of human movement, pp. 1–3, Williams and Wilkins, Baltimore, 1988.
Grood ES, Suntay WJ, Noyes FR, et al. Biomechanics of knee extension exercise. Journal of Bone and Joint Surgery 66-A(5): 725–734, 1984.
Harris FA. Facilitation techniques and technology adjuncts in therapeutic exercise. In Basmajian JV (Ed.) Therapeutic exercise, 9th ed., pp. 110–178, Williams and Wilkins, Baltimore, 1984.
Hawkins RJ, Misamore JW, Merritt TR. Followup of the acute nonoperated isolated anterior cruciate ligament tear. American Journal of Sports Medicine 14: 205–210, 1986.
Hejgaard N, Sandberg H, Haad A, et al. The course of differently treated isolated ruptures of the anterior cruciate ligament as observed by prospective stress radiography. Clinical Orthopedics 182: 236–241, 1984.
Henning CE, Lych MA, Glick JR. An in vivo strain gauge study of elongation of the anterior cruciate ligament. American Journal of Sports Medicine 13(1): 22–26, 1985.
Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clinical Orthopedics 144: 9–15, 1979.
Johnson RJ, Erikson E, Haggmark T, et al. Five to ten year follow-up evaluation after reconstruction of the anterior cruciate ligament. Clinical Orthopedics 183: 122–140, 1984.
Jones NL, McCartney N, McComas AJ. Human muscle power, Human Kinetics, Champaign, IL, 1986.
Jurist KA, Otis JC. Anteroposterior tibiofemoral displacements during isometric extension efforts. American Journal of Sports Medicine 13(4): 254–258, 1985.
Kanehisa H, Miyashita M. Effect of isometric and isokinetic muscle training on static strength and dynamic power. European Journal of Applied Physiology 52: 104–106, 1983.
Kaufman KR. Mathematical model of knee forces during exercise. PhD thesis, North Dakota State University, 1988.
Kieffer DA, Curnow RJ, Southwell RB, et al. Anterior cruciate ligament arthroplasty. American Journal of Sports Medicine 12: 301, 1984.
Kennedy JC, Weinberg HW, Andrews AS. The anatomy and function of the anterior cruciate ligament. Journal of Bone and Joint Surgery A(2): 223–235, 1974.
Lindahl O, Movin A. The mechanics of the knee joint. Acta Or-thopedica Scandinavica 38: 226–234, 1967.
Marshall JL, Warren RF, Wickiewicz VB, et al. The anterior cruciate ligament — the technique of repair and reconstruction. Clinical Orthopedics 143: 97, 1979.
McDaniel WJ, Dameron TD. Untreated rupture of the anterior cruciate ligament: a followup study. Journal of Bone and Joint Surgery 62-A(5): 696–705, 1980.
Mueller W. The knee: form, function and ligament reconstruction, Berlin Heidelberg, New York, 1983.
Noyes F, Movar PA, Matthews DS, et al. The symptomatic anterior cruciate deficient knee, Part 1: The long term functional disability in athletically active individuals. Journal of Bone and Joint Surgery 65-A(2): 154–162, 1983.
Pattee GA, Fox JM, Pizzo WD, et al. Four to ten year followup of unreconstructed anterior cruciate ligament tears. American Journal of Sports Medicine 17(3): 430–435, 1989.
Paulos L, Noyes FR, Grood E, et al. Knee rehabilitation after anterior cruciate ligament reconstruction and repair. American Journal of Sports Medicine 9(3): 140–149, 1981.
Renstrom P, Stanwyck TS, Johnson RJ, et al. Strain within the anterior cruciate ligament during a hamstring and quadriceps activity. American Journal of Sports Medicine 14(1): 83–87, 1986.
Ryan AJ, Allman FL. Rehabilitation of the knee following anterior cruciate ligament injury. In Sports medicine, pp. 541–548, New York Academy Press, New York, 1974.
Seto JL, Brewster CE, Lombardo SJ, et al. Rehabilitation of the knee after anterior cruciate ligament reconstruction. Journal of Orthopedics and Sports Physical Therapy 8–18, 1989.
Silfverskold JP, Steadman JR, Higgins RW, et al. Rehabilitation of the anterior cruciate ligament in the athlete. Sports Medicine 6: 308–319, 1988.
Smidt GL. Biomechanical analysis of knee flexion and extension. Journal of Biomechanics 6: 79–92, 1973.
Smillie IS. Injuries of the knee joint, 4th ed., Churchill Livingstone, Edinburgh, 1971.
Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. American Journal of Sports Medicine 15(3) 207–213, 1987.
Steindler A. Kinesiology of the human body under normal and pathological conditions, p. 63, Charles C. Thomas, Springfield IL, 1973.
Straub T, Hunter R. Acute anterior cruciate ligament repair. Clinical Orthopedics 227: 238–250, 1988.
Thorstensson A, Karlsson J, Viitasalo JHT, et al. The effect of strength training of EMG of skeletal muscle. Acta Physiologica Scandinavica 98: 232–236, 1976.
Yamamoto SK, Hartman CW, Feagan JA, et al. Functional rehabilitation of the knee: a preliminary study. American Journal of Sports Medicine 6: 288–293, 1976.
Yocum LA, Bohman DC, Noble HB, et al. The deranged knee, restoration of function — a protocol for rehabilitation of the injured knee. American Journal of Sports Medicine 6: 51–53, 1978.
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Palmitier, R.A., An, KN., Scott, S.G. et al. Kinetic Chain Exercise in Knee Rehabilitation. Sports Medicine 11, 402–413 (1991). https://doi.org/10.2165/00007256-199111060-00005
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DOI: https://doi.org/10.2165/00007256-199111060-00005