Anterior Cruciate Ligament (ACL) Rehabilitation: Difference between revisions
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[http://www.physio-pedia.com/index.php?title=Closed_Chain_Exercise Closed kinetic chain exercises] (CKC) and Open kinetic chain exercises (OKC) play an important role in regaining muscle (quadriceps, hamstrings) strength and functional knee stability. | [http://www.physio-pedia.com/index.php?title=Closed_Chain_Exercise Closed kinetic chain exercises] (CKC) and Open kinetic chain exercises (OKC) play an important role in regaining muscle (quadriceps, hamstrings) strength and functional knee stability. | ||
Closed kinetic chain exercises had become more popular than Open kinetic chain exercises in ACL rehabilitation. Some clinicians believed that CKC exercises were safer than OKC exercises because they place less strain on the ACL graft. Besides, they also believed that CKC exercises are more functional and equally effective as OKC exercises. A study that compared the amount of anterior tibial displacement in the ACL-deficient knee during (1) resisted knee extension, an OKC-exercise and (2) the parallel squat, a CKC-exercise, concluded that the ACL-deficient knee had significantly greater anterior tibial displacement during extension from 64° to 10° in the knee extension exercise as compared to the parallel squat exercise<ref name="Graham et al." /> | * Closed kinetic chain exercises had become more popular than Open kinetic chain exercises in ACL rehabilitation. Some clinicians believed that CKC exercises were safer than OKC exercises because they place less strain on the ACL graft. Besides, they also believed that CKC exercises are more functional and equally effective as OKC exercises. | ||
* A study that compared the amount of anterior tibial displacement in the ACL-deficient knee during (1) resisted knee extension, an OKC-exercise and (2) the parallel squat, a CKC-exercise, concluded that the ACL-deficient knee had significantly greater anterior tibial displacement during extension from 64° to 10° in the knee extension exercise as compared to the parallel squat exercise<ref name="Graham et al." />. | |||
* But one study there was found no difference in strain on the intact ACL between OKC and CKC exercises<ref>Keays SL, Sayers M, Mellifont DB, Richardson C. Tibial displacement and rotation during seated knee extension and wall squatting: a comparative study of tibiofemoral kinematics between chronic unilateral anterior cruciate ligament deficient and healthy knees. Knee. 2013 Oct;20(5):346-53. </ref>. | |||
* Currently, ACL grafts may respond more like the intact ACL. Therefore they argue, both types of exercise could be done safe<ref name="Negen" />. | |||
* A study that examined the effect of OKC and CKC exercises on functional activity concludes that both open kinetic chain and closed kinetic chain programs lead to an equal long-term good functional outcome<ref>Perriman A, Leahy E, Semciw AI. The Effect of Open- Versus Closed-Kinetic-Chain Exercises on Anterior Tibial Laxity, Strength, and Function Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2018 Jul;48(7):552-566. doi: 10.2519/jospt.2018.7656. Epub 2018 Apr 23. PMID: 29685058.</ref>. | |||
* In another study, group 1 carried out quadriceps strengthening only with CKC while group 2 trained with CKC plus OKC exercises starting from week 6 after surgery<ref name=":0">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</ref>. | |||
* It seemed that the addition of OKC quadriceps training after ACL reconstruction results in a significantly stronger quadriceps without reducing knee joint stability at 6 months and also leads to a significantly higher number of athletes returning to their previous activity earlier and at the same level as before injury. The authors conclude that the combination of OKC and CKC exercises is more effective than CKC exercises alone<ref>Glass, Rebekah et al. “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 : NAJSPT'' vol. 5,2 (2010): 74-84.</ref>. | |||
* However the sur | |||
===== Open-Kinetic-Chain exercises: ===== | ===== Open-Kinetic-Chain exercises: ===== | ||
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===== Open-Kinetic-Chain Knee-Extension exercises ===== | ===== Open-Kinetic-Chain Knee-Extension exercises ===== | ||
These exercises | These exercises seems to have a controversial role in ACL rehabilitation programs, because some 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.<ref name="Vijf" /> Despite these findings, OKC-extension exercises aren’t excluded in ACL-rehabilitation programs, because the same research had shown that OKC-extension exercises from 90° to 60° of flexion could be done safe, without increasing anterior tibial translation or ACL graft strain.<ref name="Vijf" /> | ||
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. | |||
However it is important to follow the progression of loads for the knee to not provoke pain or laxity. A study suggest to start doing sitted OKC leg extension after 6 weeks from surgery.<ref name=":0" /> . | |||
===== Open-Kinetic-Chain Knee-Flexion exercises ===== | ===== Open-Kinetic-Chain Knee-Flexion exercises ===== |
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Clinically Relevant Anatomy[edit | edit source]
Please see these pages for relevant anatomy: Anterior Cruciate Ligament (ACL) and Anterior Cruciate Ligament (ACL) - Structure and Biomechanical Properties
Definition/Description[edit | edit source]
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.
The ACL rehabilitation is both for conservative and surgical options. Conservative treatment of an ACL injury could be the best choice for sedentary patients. Indeed patient age, sportive activities and foremost subjective instability symptoms in daily life activities should be considered when deciding for or against ACL reconstruction[1][2].
General Considerations[edit | edit source]
The major goals of general rehabilitation of the ACL-injured knee:
- Gain full ROM of the knee
- Repair muscle strength and proprioception
- Gain good functional stability
- Reach the best possible functional level (walking, running, jumping...)
- Decrease the risk for re-injury
- (Return to sport)
Phases of ACL rehabilitation[edit | edit source]
The physiotherapy intervention could be divided in phases:
- Acute Stage
- Pre-surgical Stage or Conservative Treatment
- After surgery Stage
- Return to sport
Acute Stage[edit | edit source]
After ACL injury, regardless of whether surgery will take place or not, physiotherapy management focuses on regaining range of movement, strength, proprioception and stability. PRICE or PEACE AND LOVE should be used in order to reduce swelling and pain, to attempt full range of motion and to decrease joint effusion. An adeguate anti-inflammatory medications are used to help control pain and swelling.
The indication of use crutches and eventually a knee immobilizer could be appropriate in some patients. However extended use of the knee immobilizer should be limited to avoid quadriceps atrophy.
The neuro-muscular inhibition of the quadriceps caused by intrarticular effusion may have a negative effect on the strenghtening. In any case in acute stage exercises should encourage range of movement, initial strengthening of the quadriceps and hamstrings, and eventually proprioception.
To assist pre-operative optimisation, the following guidelines are recommended in the acute and sub acute stages post injury:[3][4] [5]
- Full extension is obtained by doing:
- Passive knee extension: the physiotherapist can provide the passive knee extension both with manual therapy and teaching exercises adding leverage to gently force extension,
- Patellar self-mobilisations
- Heel Props,
- Prone hang exercise,
- Static quads/SLR
- Bending (Flexion) is obtained by doing:
- Passive knee bend: the physiotherapist can provide the passive knee flexion both with manual therapy and teaching exercises adding leverage to gently force flexion
- Knee flexion in prone (gentle kicking exercises)
- Wall slides,
- Heel slides.
- Knee flexion/extension in sitting
- Ankle DF/PF/circumduction
- Glutes medius work in side lying
- Gluteal exercises in prone
- Weight transfers in standing (forwards/backwards, side/side)
It is also demonstrated that Neuromuscular Electrical Stimulation (NMES) combined with exercise is more effective in improving quadriceps strength than exercise alone[6].
It could be useful also consider taping to provide stability and to encourage reduction in swelling.
There is no a clear distinction between the Acute stage and the Pre-operative stage: the two stages could last some days each or several months before surgery. Didactically the end of the Acute stage occours when the patient regain full range of motion of the knee in extension and at least 110 degrees of flexion or a near-normal gait pattern.
Before Surgical Stage[edit | edit source]
As the Acute Stage is over it is important to prepare the knee for surgery as well as possible to optimise the outcome. The focus needs to be on strenght and proprioception. Despite of this the physiotherapist must keep the injured knee in a quiescent state improving range of motion with minimal swelling.
RICE and electrotherapy can be applied during several weeks ahead of the surgery in order to obtain full range of motion and to decrease joint effusion. The patient should also have a normal gait pattern: because of that it is useful analyse the motion of the leg in the swing phase of walking and in the one-leg-standing phase . Thus will help the patient to regain faster motion and strength after the surgery[7].
The length of this pre-surgical stage can last a few days or a several week. Because of that the role of physiotherapist it is also to mantain the compliance of the patient. For this reason the rehabilitation program must have measurable weekly objectives to improve muscular strenght and conditioning, to gain range of motion and to get better on proprioception. Thus will provide to the patient new goals to perform week by week: the compliance for treatment will be mantain achieving those.
During the pre-surgical stage is it important offer different way to renforce both muscular strenght and proprioception. Because of that it could be a good solution give to the patient two different plans of exercises to do in gym and at home. However it is very important give to the injured knee sub-massimal loads to avoid knee swelling or re-injuring for lack of proprioception.
- Develop muscle strength: Once 110 degrees of flexion has been achieved you may begin to work on muscular strength. Examples of exercises are:
- Swimming (avoid breaststroke),
- Low impact exercise machines such as an elliptical cross-trainer, Stationary Bicycle and treadmill,
- Leg press machine,
- Leg curl machine or Leg Extension machine, (see Open-Kinetic-Chain below)
- Weight bearing exercises such as squats, lunges, steps up, (see Closed-Kinetic-Chain exercises below);
- Improve proprioception:
- one-leg- standing exercise
- one-leg standing exercise adding balance cushions or cues for the arms (throwing or catching a ball, reaching targets...)
- one-leg standing exercise in different planes (frontal, sagittal)
- preparation for controlled jumps;
- Keep the compliance to rehabilitation program high;
- Mental preparation: Patient must know what to expect of the surgery and understand the rehabilitation phases after surgery.[3][8]
After Surgery[edit | edit source]
Three factors are important:
- Early terminal knee extension equal to the contralateral side,
- Early weight bearing,
- Closed and Open Kinetic Chain strengthening exercises.
Early knee extension establishes the foundation for the entire rehabilitation program. The incidence of knee flexion contracture with associated quadriceps weakness and extensor mechanism dysfunction following ACL reconstruction has significantly decreased with accelerated knee extension immediately after surgery.
Week 1[edit | edit source]
- Regular icing and elevation are used to reduce swelling. The goal is full extension and 70 degrees of flexion by the end of the first week. Use a knee brace and crutches according with surgeon and only if needed.
- Multidirectional mobilizations of the patella should be included for at least 8 weeks. Other mobilization exercises in the first 4 weeks are passive extension of the knee (no hyperextension) and passive and active mobilization towards flexion.
- Strengthening exercises for the calf muscle, hamstring and quadriceps (vastus medialis) can be performed supine or prone.
Early weight bearing appears beneficial and may decrease patellofemoral pain. Early motion is safe and may help avoid problems with later arthrofibrosis. Continuous passive motion is not warranted to improve rehabilitation outcome in patients and can avoid the increased costs associated with CPM. Minimally supervised physical therapy in selected motivated patients appears safe without significant risk of complications.
Week 3-4[edit | edit source]
- Regular icing and elevation could be used to reduce swelling. The first goal is maintain full extension and increase degrees of flexion week by week.
- The use of the knee brace is progressively reduced.[7][4] Postoperative rehabilitative bracing either in extension or with the hinges opened for range of motion does not offer significant advantages over no bracing.[9] The need for postoperative functional bracing and for consensus involving the duration of the bracing in many rehabilitation protocols comes into question. Harilainen et al have compared the effects of functional bracing after ACL reconstruction against not bracing post- operatively. No significant difference in functional outcome, degree of stability, or isokinetic muscle torque was detected at 1 and 2 yrs postoperatively between the two groups. In a similar study, Risberg et al found no significant differences in knee-joint laxity, range of motion, muscle strength, functional knee tests, or pain. [9]
- Try to genuinely increase the stance phase in an attempt to walk with one crutch. With good hamstring/quadriceps control, the use of crutches can be reduced earlier.
- Strengthening exercises for the calf muscle, hamstring and quadriceps (vastus medialis) can be performed sitting using Stationary Bicycle or light weights . The progress of the exercise depends on pain, swelling and quadriceps control.
- In some patient with good hamstring/quadriceps control it is possible genuinely attempt some exercise in Closed Kinetic Chain (half-squats, hip hinges, calfs, step up...). Usually those exercise are performed by patients who trained a long period in a good pre-surgical stage program.
Quadriceps strength is enhanced with early extension and weight bearing. The combination of early knee extension, early weight bearing, and closed kinetic quadriceps strengthening allows the patient to progress through the post-operative rehabilitation period at a rather rapid pace without compromising ligamentous stability.[3]
Week 5[edit | edit source]
- Passive mobilizations should normalize motility but flexion should not yet be thorough.
- Tonification of hamstrings and quadriceps can start with more intensity both in open and close chain exercises. The exercises should be started on light intensity (50% of maximum force) and now progressively increased to 60-70%. The closed chain exercises should be built from less responsible positions (leg presses, step) to more congested starting positions (ex.squad). The progress of the exercise depends on pain, swelling and quadriceps control.
- Proprioception and coordination exercises can start if the general strength is good. This includes balance exercises on boards and toll.
Week 10[edit | edit source]
- The progression of loading is the fundamental from now on.
- The proprioception and coordination exercise could be more specific to the individual sport needs of the patient. If is not in the patient's will the return to sport those exercise can provide to resolve his the ADL needs (as doing stairs, walking uphill or downhill, skating, swimming...)
- Forward, backward and lateral dynamic movements can be included as well as isokinetic exercises[4].
Month 3[edit | edit source]
- After 3 months, patient can move on to functional exercises as running and jumping.
- As proprioceptive and coordination exercises become heavier, quicker changes in direction are possible. To stimulate coordination and control through afferent and efferent information processing, exercises should be enhanced by variation in visible input, surface stability (trampoline), speed of exercise performance, complexity of the task, resistance, one or two-legged performance, etc.[4].
Month 4-5[edit | edit source]
- Final goal is to maximize endurance and strength of the knee stabilizers, optimize neuromuscular control with plyometric exercises and to add the sport-specific exercises.
- Acceleration and deceleration, variations in running and turning and cutting manoeuvres improve arthrokinetic reflexes to prevent new trauma during competition.[5]
Open versus Closed Kinetic Chain Exercise[edit | edit source]
Closed kinetic chain exercises (CKC) and Open kinetic chain exercises (OKC) play an important role in regaining muscle (quadriceps, hamstrings) strength and functional knee stability.
- Closed kinetic chain exercises had become more popular than Open kinetic chain exercises in ACL rehabilitation. Some clinicians believed that CKC exercises were safer than OKC exercises because they place less strain on the ACL graft. Besides, they also believed that CKC exercises are more functional and equally effective as OKC exercises.
- A study that compared the amount of anterior tibial displacement in the ACL-deficient knee during (1) resisted knee extension, an OKC-exercise and (2) the parallel squat, a CKC-exercise, concluded that the ACL-deficient knee had significantly greater anterior tibial displacement during extension from 64° to 10° in the knee extension exercise as compared to the parallel squat exercise[10].
- But one study there was found no difference in strain on the intact ACL between OKC and CKC exercises[11].
- Currently, ACL grafts may respond more like the intact ACL. Therefore they argue, both types of exercise could be done safe[4].
- A study that examined the effect of OKC and CKC exercises on functional activity concludes that both open kinetic chain and closed kinetic chain programs lead to an equal long-term good functional outcome[12].
- In another study, group 1 carried out quadriceps strengthening only with CKC while group 2 trained with CKC plus OKC exercises starting from week 6 after surgery[13].
- It seemed that the addition of OKC quadriceps training after ACL reconstruction results in a significantly stronger quadriceps without reducing knee joint stability at 6 months and also leads to a significantly higher number of athletes returning to their previous activity earlier and at the same level as before injury. The authors conclude that the combination of OKC and CKC exercises is more effective than CKC exercises alone[14].
- However the sur
Open-Kinetic-Chain exercises:[edit | edit source]
Characteristics[edit | edit source]
- Non-weight bearing
- Movement occurring at a single joint: isolation movements that promote more shearing forces[10]
- Distal segment free to move
- Resistance is usually applied to the distal segment
Open-Kinetic-Chain Knee-Extension exercises[edit | edit source]
These exercises seems to have a controversial role in ACL rehabilitation programs, because some 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.[7] Despite these findings, OKC-extension exercises aren’t excluded in ACL-rehabilitation programs, because the same research had shown that OKC-extension exercises from 90° to 60° of flexion could be done safe, without increasing anterior tibial translation or ACL graft strain.[7]
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.
However it is important to follow the progression of loads for the knee to not provoke pain or laxity. A study suggest to start doing sitted OKC leg extension after 6 weeks from surgery.[13] .
Open-Kinetic-Chain Knee-Flexion exercises[edit | edit source]
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.[15]
Closed-Kinetic-Chain Knee exercises[edit | edit source]
Characteristics[edit | edit source]
- Weight bearing
- Movement at several joints: compound movements that generally incur compressive forces[10]
- Distal segment fixed to a surface: the extremity remains in constant contact with the immobile surface, usually the ground[16]
- Resistance may be applied both proximally and distally: the entire limb is loaded[16].
Closed-Kinetic-Chain Knee exercises[edit | edit source]
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 tibiofemoral joint compression, that also reduces tibiofemoral shear forces .[10]
CKC exercises have several advantages compared with OKC exercises
- Increase stability in the knee joint (more joint compression)
- Functional load
- Strong coordinative training
- Minimal shear force
- Less stress on the ACL
- Training of the entire extension chain [17]
- 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
Bynum et al. (1995) concludes that closed kinetic chain exercises are safe, effective, and sacrifice some important advantages over open kinetic chain exercises. [15]
A more recent systematic review[18] of RCTs comparing OKC vs CKC exercises in patients post-ACLR has found that:
- There is no or insufficient evidence to demonstrate difference between OKC & CKC for pain scores or joint laxity
- the former could be explained by (1) lack of sensitivity with used questionnaire, (2) statistical power of analysis was insufficient, or (3) there is actually no difference in pain experienced by patients undertaking OKC vs CKC
- "There is weak evidence that open chain exercises are better for improving knee extensor strength, this is countered by weak evidence for better active knee flexion in closed chain activities."
Examples[edit | edit source]
Postoperative phase 1 ( 1-5 weeks)[edit | edit source]
Exercises 1:
- The first CKC-exercises are sitting exercises because they facilitate flexion and extension movements in the knee [9].
- The patient lying on a table has to extend the knee against resistance from a stretcher.
[19] | [20] | [21] |
[22] | [23] | [24] |
Return to Sport[edit | edit source]
An ACL injury leads to static and functional instability that causes changes in motion patterns and an increased risk of osteoarthrosis. In many cases, an ACL injury results in a premature end to a career in sports. [25]
[26] |
Strength and power deficits after surgery may be a risk factor for future injuries and may set athletes up for failure when they try to return to their prior performance levels. Researchers suggest that the surgically repaired leg should perform at least 90% as well as the uninjured leg before you return to sport[27]. Three hopping tests can be used as part of a comprehensive physical and functional examination to help ensure not just a speedy, but a safe return to sport after ACL reconstruction. These3 tests are sensitive enough to measure side-to-side differences and can be used during more advanced recovery phases after surgery to help ensure that the athlete’s exercise program is successful in returning the injured leg at least to the level of the uninjured leg[27].
When Should an Athlete Return to Sport After an ACL Surgery?
Other Considerations[edit | edit source]
Suggestions From the Field for Return-to-Sport Rehabilitation Following Anterior Cruciate Ligament Reconstruction: Alpine Skiing[28]
Late stage rehab ideas with specifics for the female athlete
In a retrospective, cross-sectional analysis conducted by Culvenor et al.[29]. 30% of patients had patellofemoral pain (PFP) 12-15 months following ALCR using a hamstring graft. Those who were 27 and older were 2.6 times more likely to report PFP. Patellofemoral cartilage lesions, mensical tears (both assessed by arthroscopy), pre-injury activity level, time from injury to surgery and sex were not predictors of post-operative PFP.
Those who hadPFP did not have reduced range of movement but performed worse at hop distance and single leg tasks. Patients also reported significantly lower quality of life, poor returning sport attitudes and increased kinesiophobia.
PFP is important to consider as maladaptive, fear avoidance patterns of movement perpetuate pain and functional disability by lowering pain experience thresholds. The use of appropriate language during rehab and psychosocial interventions are recommended.
Rehab Protocols[edit | edit source]
Evidence for Open and Closed Chain Exercises[edit | edit source]
Bracing[edit | edit source]
While bracing remains controversial[9], this video explains the concepts behind the action of a brace to protect the ACL.
Adjuncts[edit | edit source]
NMES - Neurotech's Kneehab XP Quadriceps Therapy System has been shown to significantly improve rehab following ACL reconstruction[31].
Presentations[edit | edit source]
![]() |
Non-Operative Management for ACL Deficiency
This presentation, created by Bill Garcia, as part of the Evidence in Motion OMPT Fellowship, discusses the current best evidence for non-surgical rehabilitation of ACL tears. Non-Operative Management for ACL Deficiency/ View the presentation |
References[edit | edit source]
- ↑ Konrads C, Reppenhagen S, Belder D, Goebel S, Rudert M, Barthel T. Long-term outcome of anterior cruciate ligament tear without reconstruction: a longitudinal prospective study. Int Orthop. 2016 Nov;40(11):2325-2330.
- ↑ Mall NA, Frank RM, Saltzman BM, Cole BJ, Bach BR Jr. Results After Anterior Cruciate Ligament Reconstruction in Patients Older Than 40 Years: How Do They Compare With Younger Patients? A Systematic Review and Comparison With Younger Populations. Sports Health. 2016 Mar-Apr;8(2):177-81.
- ↑ 3.0 3.1 3.2 Dr. P. J. Millett et al. ACL Reconstruction Rehabilitation Protocol. Sports Medicine and Orthopaedic Surgery 2010.
- ↑ 4.0 4.1 4.2 4.3 4.4 S. van Grinsven, R. E. H. van Cingel, C. J. M. Holla, C. J. M. van Loon. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010; 18:1128–1144
- ↑ 5.0 5.1 Savio L-Y. Woo, Richard E. Debski, PhD, John D. Withrow, Marsie A. Janaushek. Biomechanics of Knee Ligaments. The American Journal of Sports medicine 1999;27:533
- ↑ Kyung-Min KiM, Ted Croy, Jay HerTel, SuSan Saliba. Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function, and Patient-Oriented Outcomes: A Systematic Review. JOSPT, 2010;40(7):383-391.
- ↑ 7.0 7.1 7.2 7.3 I Eitzen, H Moksnes, L Snyder-Mackler, MA Risberg. Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. JOSPT, 2010;40(11):705-722
- ↑ Cascio B, Culp L, Cosgarea A (2004) Return to play after anterior cruciate ligament reconstruction. Clin Sports Med 23:395–408
- ↑ 9.0 9.1 9.2 Rick W. Wright et al. ACL Reconstruction Rehabilitation: A Systematic Review Part I. J Knee Surg. 2008;21(3): 217–224.
- ↑ 10.0 10.1 10.2 10.3 Graham VL. et al. Electromyographic evaluation of closed and open kinetic chain knee rehabilitation exercises. J Athl Train 1993;28(1):23-30.
- ↑ Keays SL, Sayers M, Mellifont DB, Richardson C. Tibial displacement and rotation during seated knee extension and wall squatting: a comparative study of tibiofemoral kinematics between chronic unilateral anterior cruciate ligament deficient and healthy knees. Knee. 2013 Oct;20(5):346-53.
- ↑ Perriman A, Leahy E, Semciw AI. The Effect of Open- Versus Closed-Kinetic-Chain Exercises on Anterior Tibial Laxity, Strength, and Function Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2018 Jul;48(7):552-566. doi: 10.2519/jospt.2018.7656. Epub 2018 Apr 23. PMID: 29685058.
- ↑ 13.0 13.1 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
- ↑ Glass, Rebekah et al. “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 : NAJSPT vol. 5,2 (2010): 74-84.
- ↑ 15.0 15.1 EB. Bynum et al. Open Versus Closed Chain Kinetic Exercises After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Study. Am J Sports Med. 1995; 23:401-406.
- ↑ 16.0 16.1 Prof. dr. P. Vaes. Tekstboek: Onderzoek en behandeling deel IIA 2016
- ↑ Prof. dr. P. Vaes. Tekstboek: Onderzoek en behandeling deel IIA 2017.
- ↑ Jewiss D, Ostman C, Smart N. Open versus Closed Kinetic Chain Exercises following an Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. Journal of Sports Medicine. 2017;2017.
- ↑ Mike Henkelman. ACL Rehab Forum: Therapy - Week 1. Available from: http://www.youtube.com/watch?v=n5AG4eaTS-A [last accessed 04/10/14]
- ↑ Mike Henkelman. ACL Rehab Forum: Therapy - Week 3. Available from: http://www.youtube.com/watch?v=6fGhPKUI0Us [last accessed 04/10/14]
- ↑ Mike Henkelman. ACL Rehab Forum: Therapy - Week 5. Available from: http://www.youtube.com/watch?v=NbFzjZAri-w [last accessed 04/10/14]
- ↑ Mike Henkelman. ACL Rehab Forum: Therapy - Week 10. Available from: http://www.youtube.com/watch?v=uibgRUgKNeQ [last accessed 04/10/14]
- ↑ Mike Henkelman. ACL Rehab Forum: Therapy - Weeks 12-13. Available from: http://www.youtube.com/watch?v=V1hg7sBH67U [last accessed 04/10/14]
- ↑ Mike Henkelman. ACL Rehab Forum: Therapy - Week 15. Available from: http://www.youtube.com/watch?v=NR8pINSvlag [last accessed 04/10/14]
- ↑ Kvist J. Rehabilitation Following Anterior Cruciate Ligament Injury Current Recommendations for Sports Participation. Sports Medicine 2004: 269-267.
- ↑ Atlantic Physical Therapy Center. ACL level 4 Test. Available from: http://www.youtube.com/watch?v=dEdr3Of8tUk[last accessed 04/10/14]
- ↑ 27.0 27.1 Gregory D. Myer, Laura C. Schmitt, Jensen L. Brent, Kevin R. Ford, Kim D. Barber Foss, Bradley J. Scherer, Robert S. Heidt Jr., Jon G. Divine, Timothy E. Hewett.Utilization of Modified NFL Combine Testing to Identify Functional Deficits in Athletes Following ACL Reconstruction. J Orthop Sports Phys Ther 2011;41(6):377-387.
- ↑ Kokmeyer, D., Wahoff M., Myhern M. Suggestions From the Field for Return-to-Sport Rehabilitation Following Anterior Cruciate Ligament Reconstruction: Alpine Skiing. JOSPT, April 2012, 42(4):313-325.
- ↑ Culvenor AG, Collins NJ, Vicenzino B, Cook JL, Whitehead TS, Morris HG, et al. Predictors and effects of patellofemoral pain following hamstring-tendon ACL reconstruction. J Sci Med Sport. 2015.
- ↑ DJO Global Products. Biomechanics of the Knee: ACL - with Professor Jim Richards. Available from: http://www.youtube.com/watch?v=vVYrHsnfMAg[last accessed 04/10/14]
- ↑ Sven Feil, John Newell, Conor Minogue and Hans H. Paessler. The Effectiveness of Supplementing a Standard Rehabilitation Program With Superimposed Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized, Single-Blind Study. Am J Sports Med February 22, 2011 Summary