Strain on the Anterior Cruciate Ligament

during Closed Kinetic Chain Exercises

ANNETTE HEIJNE', BRADEN C. FLEMING2 , PER A. RENSTROM', GLENN D. PEURA 3
BRUCE D. BEYNNON3 , and SUZANNE WERNER'
'Section of Sports Medicine, Department of Surgical Science, Karolinska Hospital, Stockholm, SWEDEN; 2 Bioengineering
Laboratory, Brown Medical School/Rhode Island Hospital, Providence, RI; and 3McClure Musculoskeletal Research
Center, Department of Orthopaedics & Rehabilitation, University of Vermont, Burlington, VT

ABSTRACT
HEIJNE, A., B. C. FLEMING, P. A. RENSTROM, G. D. PEURA, B. D. BEYNNON, and S. WERNER. Strain on the Anterior Cruciate
Ligament during Closed Kinetic Chain Exercises. Med. Sci. Sports Exerc.. Vol. 36, No. 6. pp. 935-941, 2004. Purpose: The purpose
of this investigation was to characterize the ACL strains produced during four commonly prescribed CKC exercises; the step-up, the
step-down, the lunge, and the one-legged sit to stand. We hypothesized that the ACL strains produced during the lunge and one-legged
sit to stand exercises (the exercises that challenge the leg musculature to a greater extent and utilize greater hip flexion) would be less
than those produced during the step-up and step-down exercises. Methods: The strains in the anteromedial bundle of the ACL were
measured while nine subjects, who had normal ligaments, performed the four exercises. Peak ACL strain values and the ACL strain
patterns as a function of knee flexion angle were compared between exercises. Results: No significant differences were found between
the peak ACL strain values (mean + SEM) between exercises (step-up: 2.5 + 0.36; step-down: 2.6 0.34; lunge 1.9 + 0.50;
one-legged sit to stand: 2.8 + 0.27). The mean ACL strain values as a function of knee flexion angle were not significantly different.
On average, there was a significant increase in ACL strain as the knee was extended for each exercise. Conclusions: The ACL strain
responses produced during these CKC exercises were equal and similar to those produced during other rehabilitation exercises (i.e.,
squatting, active extension of the knee) previously tested. Key Words: REHABILITATION, ACL, IN VIVO, LUNGE, STEP
TRAINING

T he optimal program to rehabilitate the healing graft

after anterior cruciate ligament reconstruction has
T been extensively studied (9,14,18,19,23,24). Closed
kinetic chain (CKC) exercises rather than open kinetic chain
(OKC) exercises play a primary role in ACL rehabilitation
protocols. A CKC exercise is one where the foot is opposed
by "considerable resistance" (e.g., squatting, bicycling).
CKC activities are modeled as closed linkages where move-
ment in one joint produces movements in all the other joints
of an extremity (23). Conversely, an OKC exercise is one
where the distal segment is free to move across one joint
independently (e.g., kicking, active extension of the knee) (23).
The rationale for prescribing CKC exercises after ACL
reconstruction is based on the hypotheses that: 1) CKC
exercises simulate the functional movements that are com-
mon in sports and the activities of daily life (23) and 2) CKC
exercises increase tibiofemoral joint compression and em-
phasize co-contraction between hamstrings and quadriceps
Address for correspondence: Annette Heijne, Section of Sports Medicine,
Department of Surgical Science, Karolinska Hospital, 171 76 Stockholm,
Sweden; E-mail: heijne@telia.com.
Submitted for publication November 2003.
Accepted for publication February 2004.
0195-9131/04/3606-0935
MEDICINE &SCIENCE IN SPORTS & EXERCISE
Copyright 2004 by the American College of Sports Medicine
DOI: 10.1249/01.MSS.0000128185.55587.A3
935
muscles (23). Thus, they are thought to stabilize the joint
and minimize the strain on the healing ACL graft (9,22,29).
However, there is evidence to suggest that CKC exercises
may not strain shield the healing ACL graft (5). It has been
determined that the peak strains produced on the ACL
during active extension (an OKC exercise) and squatting (a
CKC exercise) were equivalent (5). However, it has been
shown that increasing the resistance torque across the knee
joint (in an effort to increase the magnitude of the muscle
forces) during an OKC exercise will further increase the
peak ACL strains while a similar increase in resistance
during a CKC exercise will not (13). This finding suggests
that one of the advantages of CKC exercises is that the
compressive load produced by body weight and muscle
co-contraction may attenuate the peak strain values with an
increase in resistance.
There are numerous CKC exercises commonly used to
rehabilitate the ACL graft. Several authors have analyzed
the relationship between CKC exercises and the interseg-
mental loads at the knee (9,18,22,28,30). Stuart et al. (28)
analyzed the muscle activity and the intersegmental forces
about the tibiofemoral joint during two different squatting
exercises and the lunge using EMG, video, and force plate
measurements. Using an inverse dynamic model, they de-
termined that the net shear forces of the tibiofemoral joint
for all three CKC exercises remained posterior (tibia relative
to the femur) throughout the flexion-extension cycle. This
finding implies that the ACL, or ACL graft, would not be
strained during these exercises. However, the distribution of
the net joint loads between the structures of the knee re-
mains unknown.
After ACL reconstruction, it is necessary to minimize
muscle atrophy by prescribing exercises that challenge the
knee muscles while protecting the healing ACL graft. Con-
ventional physical therapy programs incorporate different
CKC exercises that increase muscle activity, though the
strain environment of the graft remains unknown.
The objective of this investigation was to characterize the
ACL strains produced during four commonly prescribed
CKC exercises: I) the step-up, 2) the step-down, 3) the
lunge, and 4) the one-legged sit to stand. The research
hypothesis was that the ACL strains produced during the
lunge and one-legged sit to stand exercises (the exercises
that would challenge the leg musculature to a greater extent)
are less than those produced during the step-up and step-
down exercises. This experiment was performed using sub- FIGURE 1-The DVRT was arthroscopically inserted on the antero-
jects with intact ligaments. It was assumed that the exercises medial bundle of the ACL. The hody or the transducer is approxi-
mately 5 mm in length. The fixation barbs are 3-mm long and pene-
that produced higher strains on the ACL would produce trate into the ligament (11).
higher strains on a healing ACL graft.

ing (Tegaderm; 3M, St. Paul, MN) for the duration of the
METHODS
test protocol. The electrical connection and removal sutures
Test subjects. Nine subjects (five males and four fe- of the DVRT exited through the lateral portal to enable data
males) who were candidates for arthroscopic partial menis- acquisition and removal of the transducer after the experi-
cectomy (six subjects) or debridement (three subjects) under ment was completed.
local anesthesia volunteered for this study (Table 1). Their The ACL displacement measurements were converted to
ages ranged from 20 to 49 yr (mean age = 31 yr). None of strain using the engineering strain formulation (6). Strain
the subjects had a history of a knee ligament injury nor did was equal to the change in length of the anteromedial bundle
they show any evidence of an injury via clinical and arthro- of the ACL relative to a reference length divided by the
scopic examinations. The study received approval from the reference length and expressed as a percentage. The refer-
Ethics Committee of the Karolinska Hospital and the Insti- ence length was established by plotting DVRT displacement
tutional Review Board at the University of Vermont. All as a function of the anterior shear load applied to the tibia
subjects granted their informed consent before participating. during an instrumented Lachman test (6,10). The DVRT
Strain measurement technique. Dispiacement mea- length corresponding to the inflection point of the load-
surements of the anteromedial bundle of the ACL were displacement curve served as the reference. This reference
measured using a differential variable reluctance transducer length has been shown to correspond to the slack-taut tran-
(DVRT; MicroStrain, Burlington VT) (6). The small dis- sition length of the ACL (10). Thus, a positive strain value
placement transducer was arthroscopically applied to the indicates that the anteromedial bundle of the ACL was under
ACL through a lateral parapatellar portal as previously strain, hence load bearing, whereas a negative strain indi-
reported (6). Because the surgery was performed under local cates that it was slack, or nonload bearing.
anesthesia, a tourniquet was not used. The measurement Experimental protocol. Immediately after the routine
axis of the transducer was aligned with the anteromedial surgical procedure, the DVRT was implanted on the ACL.
bundle and attached to the ligament midsubstance (Fig. 1). The portals were sealed, and an electrogoniometer (CA-
The arthroscopic portals were covered with a sterile dress- 4000; Orthopaedic Systems Inc, Hayward, CA) was at-
tached to the thigh and lower leg to record knee flexion
angles. The patient was then escorted off the operating table
TABLE 1.The clinical data for the nine subjects. to perform three repetitions of the four rehabilitation exer-
Involved Surgical cises under investigation: I) the step-up (Fig. 2A), the
Age Sex Side Procedure
step-down (Fig. 2B), the lunge (Fig. 2C), and the one-legged
Pat 1 20 Male Left LM
Pat 2 25 Female Left P sit to stand (Fig. 2D). The exercise testing order was ran-
Pat 3 49 Female Left LM domized. The outputs of the DVRT (the ACL displacement
Pat 4 34 Male Left PD, P response) and the electrogoniometer (the knee flexion an-
Pat 5 32 Male Left LM
Pat 6 30 Female Right MM gle) were recorded as each subject performed the exercises.
Pat 7 37 Female Left FD, PD A physiotherapist was in the operating room to provide
Pat 8 24 Male Left MM
Pat 9 30 Male Right LM instruction and overlook the performance of each exercise.
LM, lateral meniscectomy; MM, medial meniscectomy; P, plica debridement; FD, For the lunge, the subjects were instructed to position their
femoral chondral debridement; PD, patellar chondral debridement. upper body over the knee of the front leg (the instrumented
936 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
 s)
W
,,Y
- X
D)
'Y - n
A |
FIGURE 2-Four closed kinetic chain exercises that are commonly
prescribed after ACL reconstruction were compared: A. the step-up
exercise, B. the step-down exercise, C. the lunge exercise, and D. the
one-legged sit to stand exercise.
knee) to align the torso center of gravity with the knee joint.
The back leg served as a stabilizer to maintain balance. For
the step-up, step-down, and the one-legged sit to stand, the
subjects were instructed to move normally. All subjects
practiced each exercise two to three times before data
were collected.
An instrumented Lachman test was performed both be-
fore and immediately after the exercise testing protocol.
Anterior-posterior directed shear loads, between the limits
of -90 (posterior) and + 130. (anterior) Newtons, were
applied to the tibia while the knee was supported at 300 of
flexion while the femur was aligned in the horizontal plane
(6). The shear loads were applied perpendicular to the long
axis of the tibia at the level of the tibial tuberosity. The
subjects were instructed to relax their leg musculature dur-
ing the test. The data that were obtained during the repeated
Lachman test served two purposes: I) to determine the
reference for the strain calculation (10), and 2) to serve as a
"4repeated nonnal" to ensure that the DVRT measurements
were reproducible (6). After completion of the repeated
Lachman test, the lateral arthroscopic portal was re-
opened and the DVRT was removed by pulling on the
removal sutures.
ACL STRAIN AND CLOSED KINETIC CHAIN EXERCISES
Statistical analyses. The peak ACL strains produced
during the four exercises for the flexion and extension
portion of the cycle were compared using a two-way re-
peated measures analysis of variance. The two within sub-
ject factors were exercise type and cycle direction. The ACL
strain patterns (i.e., ACL strain as a function of knee flexion
angle) were compared using a three-way repeated mea-
sures analysis of variance. The three within-subject fac-
tors were exercise type (step-up, step-down, lunge, and
one-legged sit to stand), knee flexion angle (300, 500, and
700) and cycle direction (flexion vs extension). Fisher's
least significant difference procedure was used to make
pairwise comparisons.
The strain reference values that were obtained from the
"repeated normal" Lachman tests were compared using a
paired t-test to ensure that the DVRT measurements did not
change (6). The interclass correlation coefficient was cal-
culated to ensure reproducibility of the sensor. Statistical
significance for all analyses were determined at a = 0.05.
RESULTS
Peak ACL strain. No significant differences were
found between the peak ACL strain values produced due to
exercise type (P = 0.25) or by cycle direction (P = 0.34)
(Table 2). The average peak ACL strains produced during
the step-up exercise were 2.5% (SEM = +0.36) during the
extension portion of the exercise cycle and 2.5% (SEM =
0.3 1) during the flexion portion of the exercise cycle. The
average peak ACL strains produced during the step-down
exercise were 2.5% (SEM = 0.34) during the extension
portion of the exercise cycle and 2.6% (SEM = +0.34)
during the flexion portion of the exercise cycle. The average
peak ACL strains produced during the lunge was 1.8%
(SEM = 0.62) during the extension portion of the exercise
cycle and 2.0% (SEM = +0.50) during the flexion portion
of the exercise cycle. The average peak ACL strains pro-
duced during the one-legged sit to stand exercise were 2.8%
(SEM = +0.23) during the extension portion of the exercise
cycle and 2.8% (SEM = +0.27) during the flexion portion
of the exercise cycle. On average, the peak strains occurred
when the knee was nearing extension (Table 2).
ACL strain patterns. No significant differences were
found between the ACL strains produced during the four
exercises when the knee was at 300, 50, and 700 of flexion
(P = 0. 15) (Fig. 3, A-D). No differences were found be-
tween the extension and flexion directions of the cycle (P =
0.18). However, the strains produced when the knees were
at 300 (1.7 0.22%; pooled mean I SEM) were signif-
icantly greater than those produced at 50 (0.7 + 0.19%)
and 700 (0. I 0.24%) of knee flexion.
"Repeated normal" testing. For the instrumented
Lachman tests performed before and after the exercises, the
mean difference in the reference strains across subjects was
equal to 0.0 0.04 mm. Because the mean change in
reference length before and after the exercise bout was not
significant (P = 0.73) and the interclass correlation coeffi-
cient of the reference lengths was high (ICC = 0.98), the
Medicine &Science in Sports & Exercises 937
TABLE 2. The peak ACL strains (and the corresponding knee flexion angle that the peak strains occurred) for the four exercises.
Patient Patient Patient Patient Patient Patient Patient Patient Patient
Exercise 1 2 3 4 5 6 7 8 9
Step-up
Extension cycle (%/o
strain) 2.51 2.65 4.62 1.9 2.4 2.18 1.79 3.45 0.75
Knee angle at peak (0) 30 25 40 25 25 40 15 20 50
Flexion cycle (%strain) 2.03 3.13 3.8 2.28 2.9 2.53 1.85 3.1 0.51
Knee angle at peak (0) 25 25 30 25 25 55 20 25 65
Knee angle range 75-25 75-25 70-15 70-20 80-25 80-40 65-15 55-20 75-50
Step-down
Extension cycle (%strain) 1.98 3.51 3.76 3.42 1.91 3.27 2.38 2.95 2.18
Knee angle at peak (0) 30 15 70 20 15 30 15 25 40
Toward ilexion (0/o
strain) 1.13 3.26 3.72 3.26 2.7 3.65 2.6 3.15 2.17
Knee angle at peak (0) 65 20 70 20 15 50 15 25 40
Knee angle range 80-20 80-15 80-25 75-20 75-15 90-25 80-15 90-25 85-40
Lunge
Extension cycle (%strain) 1.19 4 -2.02 257 1.93 3.6 2.01 2.38 0.03
Knee angle at peak (0) 30 1O 75 35 20 25 20 30 45
Toward fiexion (%strain) 0.57 3.95 0.38 2.77 1.94 4 2.37 2.44 -0.2
Knee angle at peak (0) 30 10 75 35 20 25 20 30 45
Knee angle range 105-25 SO-10 105-20 40-25 80-20 95-25 95-10 80-30 100-45
Chair
Extension cycle (%strain) 2.84 3.33 2.27 1.74 2.28 4.6 1.32 2.26 1.2
Knee angle (0) 60 15 40 25 20 30 30 90 45
Toward flexion (%strarn) 2.64 3.69 2.23 2.15 2.9 4.66 1.58 2.12 1.4
Knee angle (0) 70 15 80 30 30 30 35 90 75
Knee angle range 70-15 75-15 80-10 70-15 70-20 90-30 70-15 65-25 80-40

output of the DVRT was considered teproducible over the
exercise bout.
DISCUSSION
This study shows that the step-up, step-down, lunge, and
one-legged sit to stand exercises did not produce greater
strains on the ACL than the traditional two-legged squat (6).
The "best" exercises for rehabilitating the knee after ACL
reconstruction are those that can maximize the patients'
ability to achieve full range of joint motion while minimiz-
ing muscle atrophy and risk to further injury. Over the last
decade rehabilitation protocols are generally based on the
hypotheses that CKC exercises do not strain the anterior
cruciate ligament graft in a harmful way (24-26). Thus,
exercises like mini-squats, weight shifts and balance train-
ing are frequently prescribed in the early phase of rehabil-
itation. OKC exercises and the demanding CKC exercises
such as lunges, parallel squats, stair climbing and deep leg
press are normally introduced around 6-8 wk postopera-
tively (8,20,23,28).
No previous studies that directly measuring the strain or
force in the ligament have been performed for these four
CKC exercises. However, the ACL strains produced in this
study follow similar patterns and magnitudes to those of
other rehabilitation exercises (Table 3), such as squatting
(4,5,11,12). Using inverse dynamics, Ohkoshi et al. (22)
found that the shear forces at the knee were posteriorly
directed and increased with increased hip flexion during
knee extension during a static squat. These findings support
the indications of the present study that CKC exercises may
strain the ACL less when the hip is in a more flexed position
as compared with those with less hip flexion such as the
step-up and step-down exercises (Fig. 3).
This study suggests that all four exercises will strain a
healing graft a similar amount. The anteromedial part of the
938 Official Journal of the American College of Sports Medicine
ACL was strained as the knee neared extension for the four
exercises. However, the strain values were not greater than
those produced during a two-legged squat (5). Thus, the
high demand exercises such as the lunge could be prescribed
at the same time as a squat if and when one feels that the
squat is a safe activity to perform after ACL reconstruction.
The step-up, step-down, and the one-legged sit to stand
exercises are performed standing on one leg. With these
exercises, higher muscle forces are produced in the lower
extremity as compared with a normal squat. Thus, the use of
these exercises would allow the patient to increase the
muscle forces about the knee without significantly increas-
ing the graft forces. Finally, the strain values were similar to
those produced during active extension of the knee against
gravity, an open kinetic chain exercise that was previously
tested using the same technique (5). Therefore, these data
suggest that the OKC exercise could be initiated at the same
time during the postoperative rehabilitation program as the
more aggressive closed kinetic chain exercises. There are
secondary effects that also need to be considered when
evaluating and introducing different rehabilitation exer-
cises after ACL reconstruction, including pain, swelling,
reduced range of joint motion and proprioception, and
muscle atrophy, factors not evaluated in this laboratory
controlled study.
Mikkelsen et al. (21) demonstrated that there was no
difference in anterior knee joint laxity or function after graft
healing when comparing the early (6 wk) and late (12 wk)
introduction of OKC exercises in postoperative rehabilita-
tion programs in a prospective randomized study. Therefore,
open kinetic chain exercises are not detrimental to healing
and could play a role in postoperative care. In contrast,
Bynum et al. (8) found that the reconstructed knee of a
subject who had undergone a CKC exercise rehabilitation
program had less increased anterior knee joint laxity over
time compared with those who had undergone an OKC
http://www. acsm-msse.org
 3A. Step-up Exercise 3B. Step-down Exercise

3 3

2 21

F
1
cn
ca
U~
0 -i 0
4

-1 -I

-2 -2
20 30 40 50 60 70 80 20 30 40 50 60 70 80
Knee Flexion Angle (deg) Knee Flexion Angle (deg)

3C. Lunge Exercise 3D. 1-leg sit-stand Exercise

3 3-~

2 2-~

C
I -

.r
.-
0 C-) 0-
:

-I -1 - -0- Flexing
A Extending
-2 -2
20 30 40 50 60 70 80 20 30 40 50 60 70 80
Knee Flexion Angle (deg) Knee Flexion Angle (deg)

FIGURE 3-The mean ACL strains as a function of knee flexion angle for the four exercises: A. the step-up exercise, B. the step-down exercise, C.
the lunge, and D. the one-legged sit to stand exercise.

exercise program. Although the strain magnitudes produced
during the active knee extension exercise were similar to the
closed kinetic chain exercises tested in our study, there is
recent evidence to suggest that increasing the resistance to
the lower leg during the active extension exercise (i.e.,
quadriceps sets performed on a weight bench) will increase
the peak strain values (13). Increasing the level of resistance
during closed kinetic chain exercises does not produce this
increase (13).
The DVRT allowed for precise strain measurements of
the anteromedial bundle of the ACL. Application of multi-
ple DVRT could potentially provide a detailed mapping of
the strain distribution across the different bundles of the
ACL. Due to the size of the DVRT and the location of the
ACL with respect to the posterior cruciate ligament and the
osseous walls of the intercondylar notch, the technique is
currently limited to the anteromedial bundle using one trans-
ducer. We recognize that the ACL has a strain distribution
about its cross-section area (7). However, the measurements
presented here may be sufficient since surgeons generally
ACL STRAIN AND CLOSED KINETIC CHAIN EXERCISES
attempt to reconstruct the function of the anteromedial band
when performing an ACL reconstructive procedure (15).
This investigation was performed on subjects with normal
ACL to gain insight into the strains produced on an ACL
graft during exercise after reconstructive surgery. It is cur-
rently impossible to evaluate the strain in an ACL substitute,
in vivo, during dynamic activities that involve the leg mus-
culature because the surgical reconstruction should not be
performed under local anesthesia. Furthermore, additional
variables that are associated with the reconstructive proce-
dure would also increase the variability of the strain re-
sponse. Therefore, it is advantageous to perform these mea-
surements on the normal ACL. It seems reasonable,
however, to extend these data to the knee with a properly
positioned ACL graft. The elongation pattern of the bone-
patellar ligament-bone graft during passive extension of the
knee joint has been previously measured, in vivo, and was
found to be similar to the normal ACL (3). Thus, a loading
condition that causes a decrease in normal ACL strain
should cause a similar decrease in a properly positioned
Medicine &Science in Sports &Exercise 939
TABLE 3. Rank comparison of peak ACL strain values during commonly prescribed
rehabilitation exercises (mean SE).
Peak
Rehabilitation Activity Strain
Isometric quads contraction @15 (30 Nm of 4.4 (0.6)%
extension torque)
Squatting w/sport cord 4.0 (0.6)%
Active flexion-extension of the knee with 45-N 3.8 (0.5)%
weight boot
Lachman test (150 Nof anterior shear load; 300 3.7 (0.81%
flexion)
Squatting 3.6 (0.5)%
Active flexion-extension (no weight boot) of the 2.8 (0.8)%
knee
Simultaneous quads and hams contract on @ 150 2.8 (0.9)%
Isometric quads contraction @30 (30 NMm of 2.7 (0.5)%
extension torque)
Stair climbing 2.7 (1.2)%
Weightbearing @200 of knee flexion 2.1 (0.5)%
Anterior drawer (150 Nof anterior shear load; 90 1.8 (0.9)%
ilexion)
Stationary bicycling 1.7 (0.7)%
Isometric hams contraction @15 (to -10 Nm of 0.6 (0.9)%
tlexion torque)
Simultaneous quads and hams contraction @30 0.4 (0.5)%
Passive flexion-extension of the knee 0.1 (0.9)%
Isometric quads contraction @600 (30 Nm of 0.0%
extension torque)
Isometric quads contraction @ 900 (30 N-m of 0.0%
extension torque)
Simultaneous quads and hams contraction @600 0.0%
Simultaneous quads and hams contraction @90 0.0%
Isometric hams contraction @30, 60', and 900 0.0%
(-10 Nm of flexion torque)
ACL graft. Most likely, the strain patterns for other graft
types would be similar; however, this has not been verified.
The results of this study were based on subjects with
normal ACL undergoing arthroscopic surgery for a partial
meniscectomy, chondral debridement, or plica excision un-
der local anesthesia. Although the subjects presented with
minor cartilage or meniscal problems, the overall function
of their knee joints were assumed to be normal. Cadaver
investigations have shown that knee kinematics are not
altered in the ACL intact knee after medial or lateral me-
niscectomy (1,16,17). Thus, it seemed reasonable to assume
that a partial meniscectomy would have a negligible effect
on knee kinematics, and hence, ACL strain behavior. It is
also possible that the local anesthesia could influence the
strain response because it eliminates sensory perception
within the joint capsule. Local anesthesia, however, has not
been shown to alter knee joint proprioception (2).
The power of the analysis of variance used to compare the
peak strain values between exercises was relatively low
(approximately 30%) if we assume a minimal detectable
difference of 1% strain and alpha equals 0.05. The power
could be increased to 80% if we were to triple our sample
size. The mean peak strains that were recorded for these
exercises were less than those measured previously for the
simple squat and the passive Lachman test (5,6). Further-
more, the sample size was similar to those of our previous
studies of ACL rehabilitation where significant differences
were found. Considering the invasiveness of the experiment,
the clinical relevance of the small differences observed
between the exercises evaluated in this study is at least
questionable. Nonetheless, the low power of the analysis is
a limitation to the study.
940 Official Journal of the American College of Sports Medicine
The variability inherent to the strain measurements is
most likely related in part to the variation in exercise per-
No. of formance. The repeated normal test (i.e., the instrumented
Subjects
Lachman test) ensures us that the variability due to the
8
measurement technique is minimal. It is important to note
8 that the subjects were instructed by a physical therapist on
9
how to perform each exercise as they would in the clinic.
10 The subjects were allowed several trials of each exercise
before data was collected to eliminate any potential learning
8
18 effects. However, the position of the torso relative to the
knee was not formally controlled or documented. The loca-
8
18 tion of the center of gravity relative to the knee joint has
been shown to influence the net shear loads across the knee
5 (22). It is possible that location of the center of gravity was
11
10 different across subjects and this may account for some of
the variability.
8
8 At this time, it is not possible to identify which exercises
are safe or harmful to a healing graft because the strain
8
10 thresholds that are beneficial and/or detrimental to graft
8 healing remain unknown. Physical therapists introduce dif-
ferent types of CKC exercises postoperatively in an attempt
18
to replicate the functional movements utilized in daily life
8 and sports as soon as possible (20,24-26,28). The peak
8
8 strains produced during the quadriceps-dominated exercises
could conceivably produce damaging effects if they are
introduced too early during rehabilitation. This is particu-
larly true if they are performed with the knee joint near full
extension, or if they are advanced to more challenging levels
of muscle contraction. We know that hamstrings dominant
exercises produce little or no strain on the ACL. Step-up,
step-down, and mini-squats are usually performed with the
knee closed to full extension. Lunges and parallel squats are
performed with the hip in a more flexed position, which
make the hamstrings more activated (22,23,30). Thus, these
activities should be relatively safe for a healing ACL graft.
It is known from the literature that the co-contraction of
the quadriceps and hamstrings muscles is frequently altered
in ACL-deficient knee subjects. For example, the hamstring
activity has been shown to increase in many ACL-deficient
patients. An increase in hamstrings activity would theoret-
ically serve to decrease the shear forces on the tibia and
thereby minimize the strains on the ACL graft (27). It is
possible that the changes in co-contraction patterns seen in
ACL reconstructed patients may be lower than the subjects
with normal ACL who participated in the present study.
Whether the differences in hamstrings activity contribute
significantly to reduce ACL-loading during strenuous activ-
ities remains unknown.
Knowledge about the strain response of the healing graft
is necessary to determine which exercise should be included
in an exercise program to optimize rehabilitation of the ACL
graft. The peak strain produced during these closed kinetic
chain exercises are less than those produced during a passive
Lachman test. The strain data obtained from the normal
ACL may enable us to design prospective, randomized,
longitudinal studies to optimize rehabilitation and shed the
light on the strain thresholds that may be beneficial and/or
detrimental to the healing of different types of grafts.
http://www.acsm-msse.org
 Funding for this study was provided, in part, by grants from
National Football League Charities and the Swedish National Center
for Research in Sports.
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Medicine &Science in Sports &Exercisee 941
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TITLE: Strain on the Anterior Cruciate Ligament during Closed

Kinetic Chain Exercises
SOURCE: Med Sci Sports Exercise 36 no6 Je 2004
WN: 0415701727004

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