The Knee 20 (2013) 346–353

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The Knee

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
S.L. Keays a,⁎, M. Sayers b, D.B. Mellifont b, C. Richardson b

a
Private Practice and Faculty of Science, Health, Education and Engineering, The University of the Sunshine Coast, Queensland, Australia
b
Faculty of Science, Health, Education and Engineering, The University of the Sunshine Coast, Queensland, Australia

a r t i c l e i n f o a b s t r a c t
Article history: Background: Following anterior cruciate ligament (ACL) rupture, the knee becomes unstable with alterations
Received 18 December 2011 in joint kinematics including anterior tibial displacement (ATD), and internal tibial rotation. Therapeutic ex-
Received in revised form 28 June 2012
ercises that promote faulty kinematics should be discouraged, especially early post-reconstruction, to avoid
Accepted 8 July 2012
graft stretching and possibly longer-term osteoarthritis. Our study aimed to compare ATD and tibial rotation
during two commonly prescribed exercises, namely: open kinetic chain (OKC) seated extension and closed
Keywords:
kinetic chain (CKC) single leg wall squatting in ACL-deficient and healthy knees.
Anterior cruciate ligament
Knee joint kinematics Methods: Eight ACL-deficient patients and eight healthy subjects matched for age, gender and sports history
Open and closed chain exercises were assessed using Qualisys 3D-Motion Analysis System to track 17 infrared markers while performing a
Motion analysis seated knee extension with 3 kg weight and a unilateral wall squat. We developed a model to measure
Wall squat joint kinematics through 70° of knee flexion and extension. ANOVA and paired t-tests compared relative
ATD and tibial rotation between exercises and groups at 10° increments of flexion and extension.
Results: We found increased ATD in the wall squat compared to the seated extension (p = 0.049). There was
no difference in ATD between the healthy and ACL-deficient knees but overall the tibia was significantly more
internally rotated (p = 0.003) in ACL-deficient knees, irrespective of the exercise, possibly interfering with
the screw-home mechanism.
Conclusions: CKC exercises, in particular wall squats, are not necessarily safer for patients with ACL-deficiency
and possibly ACL-reconstruction; although generalization should only be made with appropriate caution. Cli-
nicians require a detailed knowledge of the effect of exercise on knee joint kinematics.
© 2012 Elsevier B.V. All rights reserved.

1. Introduction exercises post surgery led to major problems restoring function in

ACL injuries are increasingly common during sport and clinicians
strive to provide optimal rehabilitation to individuals with ACL defi-
ciency (ACLD) or post ACL reconstruction (ACLR). One of the ongoing
and important issues with regard to rehabilitation following ACL inju-
ry and surgery involves the scientific basis for safe exercise selection
[1]. When the ACL is ruptured the knee becomes unstable with alter-
ations in joint kinematics specifically in relation to anterior tibial dis-
placement (ATD), and internal tibial rotation [2] and any exercise that
promotes these movements should be initially avoided and later pre-
scribed with caution. The safe prescription of exercise requires de-
tailed knowledge of the effect of exercise on knee joint kinematics.
Important long-standing research has established that
quadriceps exercises may be unsafe as they have the potential to
disturb graft in- tegrity by causing increasing ATD [3,4]. However
avoiding quadriceps
⁎ Corresponding author at: PO Box 584 Nambour 4560, Queensland, Australia.
Tel.: + 61 754 41 4111; fax: + 61 754 41 7861.
E-mail address: slkeays@optusnet.com.au (S.L. Keays).
the
80s and 90s [5]. Subsequently the focus on quadriceps rehabilitation
has returned [6–8] and the critical question remains regarding
which quadriceps exercises are safe and at what stage during
rehabilitation can they be commenced. Closed kinetic chain (CKC)
exercises became favored over open chain because the
accompanying joint compression was considered to limit ATD.
However controversy regarding the safety of open versus closed
chain quadriceps exercises with regard to ATD continues. Similarly,
clinicians need to consider whether exercise type promotes
excessive tibial rotation that may interfere with stability or possibly
long term OA [9–11].
The safety of quadriceps exercises is usually determined by
either assessing strains on the ACL using transducers embedded in
the liga- ment [12,13] or more commonly by comparing the residual
ATD and ro- tational laxity present in the knee joint following
different exercise approaches. For example several authors have
compared the effect of open versus closed chain exercises on knee
joint laxity at various stages post surgery with sometimes conflicting
results. Bynum et al. [12] found that closed chain exercises resulted in
less anterior laxity as compared to standard open chain exercises.
On the other hand Tagesson et al.

0968-0160/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2012.07.005
 S.L. Keays et al. / The Knee 20 (2013) 346–353
34
[13] and Morrissey et al. [14] found no significant difference in years). Their mean age was 36 years of age (range 22 to 47 years)
anterior laxity between groups following either OKC (primarily and there
isokinetic seated knee extensions) or CKC exercises (leg press or
squatting). In the clini- cal situation squats are considered to be safer
than seated extensions as they are thought to result in less ATD [15].
However Isaac et al. [16] have shown that in certain closed chain
situations the quadriceps-generated force can strain the ACL more
than during open chain activities. We con- sider that a wall squat,
because the center of gravity is posterior and the quadriceps are
challenged, would result in equal or greater ATD com- pared to a
seated extension. Beynnon et al. [17], for example, found sim- ilar
strains on the ACL during squatting as during active flexion–
extension exercises.
Studies comparing direct measurement of ATD and tibial
rotation during execution of the task could far better assess the
effect of thera- peutic exercise, particularly if the tibial movement is
measured relative to the femur rather than the patella. The use of
three-dimensional (3D) motion analysis in patients with ACLD is an
ideal way to assess the safe- ty of exercise because it enables the
measurement of small abnormal movements like ATD and rotation
during dynamic activity. Many stud- ies (Table 1) [9–11,18–32], using
a variety of direct and often confined measures such as MRI, have
confirmed the presence of increased ATD and internal rotation in
ACLD compared to intact knees. Relatively few studies [28,29] have
used infra-red motion analysis to assess tibial translation or
rotation during clinical exercises in long-standing ACL-
deficiency. Equally few have used direct methods to compare
open and closed chain exercise safety [31,32]. Although the study of
ACLD participants introduces a question of generalizability to
ACLR populations, it has the advantage of not risking graft integrity.
Accordingly, the aim of this study was to compare ATD and
tibial rotation during open kinetic chain (OKC) seated extension and
closed kinetic chain (CKC) single leg wall squatting exercises in ACL-
deficient and healthy knees. It was hypothesized that wall squats
were no safer than seated extensions as they would cause as much or
more ATD and internal rotation as seated extensions, in both ACLD
and healthy sub- jects. Secondly it was hypothesized that more ATD
and rotation would occur in the ACLD compared to healthy
subjects. By gaining insight into the effect of exercise on tibiofemoral
kinematics, our exercise selec- tion can be scientifically directed to
maintaining graft integrity, promot- ing dynamic joint stability and
possibly to minimizing the OA changes caused by repetitive
abnormal kinematics.

2. Method

2.1. Subjects

Eight patients with chronic ACL deficiency and eight healthy

matched controls took part in this study. The patients were recruited
from an initial cohort of 28 ACLD patients who had been referred for
rehabilitation to one physiotherapist, at least two years previously, and
had opted not to have surgical reconstruction. Historically, the
patients did not go ahead with ACL surgery due either to work,
time or expense restraints or because they were able to modify
their sporting and activity demands to accommodate to their knee
instability. From the 28 patients treated non-surgically, 15 were
available to take part in the present study, seven were excluded as
they did not fulfill the inclusion criteria.
Exclusion criteria for this study were partial ACL injuries, bilateral
ACL injuries, previous ACL surgery, symptomatic OA or any other
lower limb or back problems.
Only patients with a chronic, complete unilateral anterior
cruciate ligament rupture confirmed either on arthroscopy, MRI or by
a positive pivot shift test as assessed by an orthopedic surgeon, were
included. All patients were required to be aged between 18 and 48
years of age and to have been involved in at least one sport prior to
injury.
As indicated, eight patients satisfied the inclusion criteria for this
cur- rent study. The average time post injury was 16 years (range 7–23
 S.L. Keays et al. / The Knee 20 (2013) 346–353
were three females and five males in the group. Four patients had 34
injured their right and four had injured their left knee. Table 2 lists 2.2.1. Open chain single leg knee extension
the demo- graphic data together with patient measures of instability, The OKC seated extension was performed with the patient sitting
sports played and reasons for declining surgery. high on a stable table. The subjects were asked to ‘sit tall’ and were
Eight uninjured, healthy participants were recruited following expected to maintain a neutral spine during the exercise. This may
notifi- cation displayed in the university campus, gym and golf have prevented those subjects with range restrictions in hamstring
club. The uninjured subjects were matched for age, gender, leg side and muscles and/or neural structures from extending their knee fully. A
the activity level of the pre-injured patients. There were three females 3 kg weight was applied to the foot/ankle such that it would not in-
and five males in the uninjured control group and their mean age was terfere with the visibility of the infrared markers positioned on the
33 years of age (range 19–49 years). All participants were or had been malleoli. Then the subjects were asked to straighten their knee, hold
actively involved in at least one sport with a minimum score of 6 on as straight as possible for 3 s and then lower. The timing of the activ-
the Tegner scale [33]. ity was controlled using a metronome.
As part of data collection for this current study, each of the
patients underwent another routine clinical examination involving
2.2.2. Closed chain single leg wall squat
assessment of clinical and instrumented laxity testing. All patients had
The CKC single leg wall squatting exercises required participants
a positive an- terior drawer, Lachman and/or pivot shift test and the
to stand with his/her back against a ‘wall’ (an immoveable structure
average maxi- mum anterior displacement on KT 1000 testing was
in the laboratory) with his/her index foot (heel) 30 cm from the
12.6 mm. The average maximum anterior displacement on KT 1000
wall. The non-index leg was required to be strictly non-weight-
measured on matched healthy knees has been reported as 6.02 mm
bearing (NWB) and positioned so as not to block visibility of the
[34].
infrared markers. With hands resting against the ‘wall’ the subject
This clinical examination was followed by a detailed testing of two
was asked to flex his/her index knee slowly until it was not possible
exercises in a motion analysis laboratory.
to bend fur- ther without losing balance. They were required to hold
Ethical clearance was granted, and written informed consent was
this position of maximum controlled flexion for 3 s and then rise to
obtained prior to testing in accordance with the University Human
upright standing with timing again controlled using a metronome. No
Research Ethics Committee procedures.
instructions were given regarding knee alignment during this
exercise.
2.2. Exercise details
2.3. Data collection
Prior to the data collection, each participant was briefed on the
pro- cedure and was required to practice the two exercises to be
3D kinematic data were captured at 150 Hz using a 6 camera
performed. Specific exercise instructions were scripted so that they
infrared motion analysis system (Qualisys AB, Gothenburg, Sweden).
remained con- stant for each subject. Each subject practiced the
This system was calibrated before each trial and was capable of
activity until they were familiar with and understood what was
reconstructing 3D space with a high degree of precision (SD of the
required. They performed each exercise again twice immediately
predicted calibration wand length was 0.0006 m with a mean error of
prior to data collection.
0.004 m).
 34
8

Table 1
Literature Findings using Direct Measures to Assess Tibial Displacement and Rotation in ACL-deficient and Intact Knees.

Authors Subjects

Van der Velde et 9 Cadavers before and after ACL transection

al. [18] 10 ACLD subjects

Mannel et al. 6 Cadaver knees before and after

[19] ACLD transection
Kanamori et al. 12 Cadaveric intact and ACLD knees
[20]
Carpenter et al. [21] 9 ACLR and contralateral knees

Scarvell et al. [9] 23 Chronic ACLD knees

Seon et al. [22] 20 Unilateral ACLR patients: 10 single and 10 double S.L
bundled reconstructions .
Ke
ay
Shefelbine et al. 8 ACLD and 10 healthy subjects s
[23] et
DeFrate et al. 8 Healthy and 8 ACLD subjects al.
/
[11]
Th
Jonsonn et al. 13 ACLD knees and intact knees e
[24] Kn
Georgoulis et al. 13 ACLD knees ee
[25] 21 ACLR knees 20
(2
10 Healthy knees 01
Brandsson et al. ACLD subjects 3)
[26] 34
Lysholm and ACLD and normal knees 6–
35
Messner [27] 3

Deneweth et al. 9 Unilateral ACL reconstructed subjects

[10]
Beard et al. [28] 11 ACLD subjects before and after
surgery

Waite et al. [29] 15 Unilateral ACLD subjects

Nagano et al. 24 Female athletes

[30]
Yack et al. [31] 9 Normal and 11
ACL deficient knees

Jenkins et al. 14 males 5 females

[32] Unilateral ACLD patients
350 S.L.S.L.
Keays
Keays
et al.
et /al.The
/ The
Knee
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346–353
346–353
34
The infrared markers were positioned on the test limb with

Unable to have surgery due to work and finance

subjects standing with the knee at 0° extension. Markers (7 mm)

very young children. Happy to modify activity for now

were attached to the skin over the greater trochanter, the outermost
prominence of the medial (medial epicondylar ridge) and lateral
Reason for declining surgery

femoral condyles, the medial and lateral tibial condyles 1 cm distal to

the articular margin of the tibia (directly inferior to the femoral
Happy to modify sport

markers), the most promi- nent point on the tibial tuberosity, the
center of the patella and the cen- ter of the medial and lateral
malleoli. Four marker clusters were positioned laterally mid
segment on both the thigh and shank. Marker trajectories were
modeled in 3D using standard biomechanical software (Visual3D, C-
Motion, Inc. Maryland, USA) then filtered using a 7 Hz 2nd order low
pass filter prior to the construction of a 2 segment 3D model of the
Running, surfing, bike riding

lower limb with 6 degrees of freedom. Movements in the sagittal

Gym, walking, swimming

Sports played post-injury

(anterior–posterior translation and flexion/extension) and transverse

Walking, bike riding

Cricket, golf, surfing

(internal/external rotation) planes were labeled so that they

Swimming, surfing
Hasrun

occurred about the X and Z axes respectively.

Although the Qualisys motion analysis system was calibrated to
Gym, walk,

Horse riding

less than 0.6 mm for each data collection, there are accepted errors
that impact on the accuracy of infrared motion tracking using surface
Golf

markers. For example, Benoit et al. [35] and Luchetti et al. [36]
highlighted the problems with skin movement artifacts during infra-
Soccer, surfing, skate-boarding

red motion caption. In contrast, Manal et al. [37] reported a strong

correlation with joint co-ordinate data collected via surface markers
and embedded bone pins. In effect, small changes in angles (b 1°)
Rugby, indoor cricket
Competitive netball

Competitive netball

and displacement (b 3 mm) may in part be due to known limitations

played pre injury

in motion analysis methodology and so care should be taken when

Skiing, cricket

Soccer, rugby

interpreting these data.

Netball
Cricket

2.4. Data calculation and analysis

(mm)
Sports

In order to calculate ATD relative to the femur, a reference point

1000 MMT uninjured side

and a reference plane were defined. The centrum of the distal end of
femur (Femcent) was first calculated using the midpoint of the distal
femoral markers. Next, the longitudinal axis (z-axis) of the lower leg
(ShankZ) was defined using the anatomical landmarks and standard
4.5

Visual3D modeling procedures. ATD was calculated as the linear

7

10

10

4
KT (mm)

displacement from Femcent to ShankZ in the Y–Z plane (sagittal). The

tibial rotation was calculated as the angular displacement (about
MRIMMT injured side

the longitudinal axis of the lower leg) relative to the femur. We

measured tibial motion as the knee moved through flexion and
extension and expressed tibial translation in a similar way to that
described by Jonsson and colleagues [24]. That is, the tibia moves
Demographic data and reasons for declining surgery in the ACL-deficient group. Table 2

13

15

10

13

15

13

12

11

posteriorly with flexion and from this pos- terior position the tibia
on1000

displaces anteriorly with extension. Although this methodology

precisely represents the movement of the proximal tibia relative to
Complete tearKT

the distal femur, it is perhaps more conducive to an an- atomical

rather than clinical perspective. Importantly, clinicians often
describe ATD in terms of the relative amount of tibial translation
+ ve

+ ve

when compared with stereotypically optimal motion as opposed to

+ ve

+ ve

+ ve

+ ve

+ ve

+ ve

its absolute displacement. Similarly, the measure of tibial rotation

Pivot shift status

adopted in this study, while accurate, is a relative and not absolute

measure of the orientation of the tibia in relation to the femur. This
has resulted in a net external tibial rotation, which is once again a
representative of relative positional change rather than clinical
+ ve

+ ve

+ ve

− ve

perspective.
Following data collection, all data recorded were coded into a sta-
Gender

+ ve

+ ve

+ ve
+ ve

tistical package for the social sciences ([SPSS] Version 17.0 for Win-
M

M
F

dows, SPSS Inc., USA) file for statistical analysis. ATD and rotation
Age

data were next subject to a series of separate repeated measure

46

22

24

44

41

two-way analysis of variance (ANOVA) with Bonferroni corrections

M

F
Participant # Side of injury

to determine whether changes in the orientation of the tibia relative

24

45

47

to the femur occurred with changes in knee flexion (namely at 10°,

Right

Right

Right
Left
Left

Left

20°, 30°, 40°, 50°, 60° and 70°). Subsequent to the ANOVA testing,
matched pair t-tests were used to determine where any significant
1

differences existed. Mauchly's test of sphericity was applied during

Right
Left

all ANOVA testing with Greenhouse–Geisser corrections applied

7

where data violated the sphericity assumption. The level of statistical

Fig. 1. ANOVA results showing the comparison between the amount of relative anterior translation occurring in ACL and healthy subjects pooled, during open chain knee extension
and a unilateral wall squat. Results show an overall significant effect of exercise type on the amount of anterior tibial displacement (p = 0.049).

significance was set at p b .05 and data are presented as means (± SD)
throughout.
3. Results
Statistical analyses indicated a main effect for joint angle (p b .001) with increasing
ante- rior translation with smaller knee flexion angles, that is, closer to full extension.
In addition, there was a significant effect (p = 0.049) for exercise type (CKC wall squat
compared to the OKC seated extension) in the amount of ATD (Fig. 1). Post-hoc testing
showed that ATD was significantly greater (p b 0.05) during CKC wall squats at 30°, 40°,
50°, 60° and 70° of knee flexion. Results did not show any significant differences in
the amount of ATD in ACLD patients during CKC wall squats or OKC seated extension
exercises as compared to the uninjured controls either overall (p = 0.094) or at any
specific joint angle (p > 0.05).
Representative kinematic data of a typical uninjured healthy knee during these
two exercises are shown in Fig. 2. These data show the typical pattern of greater
relative ATD as the knee extends. In contrast Fig. 3a and b present individual knee
kinematics for two of the ACL deficient participants with greater ATD seen in Fig.
3b. Fig. 3a is a
representative of several participants in this group and shows a similar profile to that
in Fig. 2. These patients, we suspect are ‘copers’, or for this cohort, more appropriately
‘adap- tors’, who are more functionally stable even with a fully ruptured ACL.
Conversely, Fig. 3b is a representative of another group of the ACLD participants and it
indicates noticeably more ATD in the CKC wall squat. These participants, we suspect
are ‘non-copers’, who are functionally unstable and unable to return to their pre-
morbid sport without surgery.
Results indicated that the amount of tibial rotation did not alter significantly for
changes in either knee angle (p = 0.362) or between CKC wall squats or OKC seated
ex- tensions (p = 0.525). However comparison by ACL status showed that there was a
sig- nificant difference (p = 0.003) in tibial rotation between the ACLD participants
and the healthy controls (Fig. 4). Subsequent analysis showed that tibial internal
rotation was different between these groups at all angles including 70°.
4. Discussion
This study hypothesized firstly, that as much or more ATD and
internal rotation would occur during wall squats compared to seated
extensions

Fig. 2. The amount of antero-posterior tibial displacement during two single leg wall squats and two seated extensions in a healthy participant.
Fig. 3. The amount of antero-posterior tibial displacement during two single leg wall squats and two seated extensions in two ACLD subjects. Fig. 3a is a representative of several
ACLD participants, possibly with more dynamically stable knees, and shows a similar profile to that in Fig. 2, with the exception of reduced extension during the wall squat
and increased ATD at 0° only, during the seated extension. Fig. 3b is a representative of a possibly less dynamically stable group of ACLD participants, who presented with
noticeably more ATD throughout range in both the CKC wall squat and OKC seated extension.

and secondly that there would be significantly more ATD and rotation
in ACLD compared to healthy subjects. We are only able to partially
accept the first hypothesis as while there was significantly more
ATD in wall squats compared to seated extensions (p = 0.049), the
difference in inter- nal rotation between exercises did not reach
significance. In addition we found that there was significantly more
internal rotation, but not ATD, in the ACLD knee compared to the
healthy knee irrespective of the exer- cise (p = 0.003).
Contrary to expectations the ACLD participants did not
consistently present with significantly greater ATD compared to the
healthy partici- pants. This may have occurred because the more
dynamically stable sub- jects behaved like intact knees as a result of
long term adaptations and physiotherapy training which maximized
the ability of muscular control in maintaining AP stability. Other
authors have found increased ATD in ACLD knees (Table 1). For
example Shefelbine et al. [23] found that be- tween 0° and 45° of knee
flexion, the ACLD knee translated a significant
352 S.L.S.L.
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et al.
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/ The
Fig. 4. ANOVA results showing the comparison between the amount of relative internal tibial rotation occurring during both open chain extension and the wall squat in ACLD and
ACL intact healthy participants. Results show an overall significant effect of ACL status on the amount of tibial rotation during knee flexion (p = 0.003).
4.3 mm anteriorly with no significant translation in the healthy
controls. DeFrate et al. [11] and Johnson et al. [24] also reported
increased ATD in the ACLD knee during static lunges and active knee
extension respective- ly. Waite et al. [29] reported no difference in ATD
in ACLD compared to in- tact knees during running and cutting.
Our study showed increased internal rotation (that is less external
ro- tation) in the ACLD knee during both exercises. Data also indicated
that external rotation decreased with extension (Fig. 4) in the ACLD
group, possibly interfering with the screw home mechanism.
Moglo and Shirazi-Adl [38] have shown that transection of the ACL
substantially in- fluences the ‘screw-home’ mechanism. Our findings
confirm what was found by DeFrate et al. [11] who reported an
increased internal rotation at low flexion angles (15°, 30° ) during a
static lunge and Brandsson et al. [26] who found an increased internal
rotation in the ACLD knee com- pared to the contralateral knee during
step up onto a box. Interestingly Zarins et al. [39] found that ACLD
knees measured at 5° of flexion demon- strated 4° more internal tibial
rotation and 5° more external rotation com- pared to ACL intact knees
when assessed passively.
This study has shown that there was significantly greater ATD at
knee angles between 30° and 70° in the wall squat compared to the
open chain seated extension (Fig. 1). The greater amount of tibial
translation occurring during the wall squat is most likely the result
of a combined result of an increased ground reaction force moment
and stronger quadriceps activation with the center of gravity posi-
tioned posteriorly. While several studies [3,40] have warned clini-
cians about the danger of ATD during OKC exercises, the danger in
relation to wall squats has, to our knowledge, not been sufficiently
described [41]. As mentioned before, Beynnon et al. [17] found
similar strains on the ACL during squatting as during active flexion–
exten- sion exercises. In addition it has been shown that wall squats
in par- ticular, increase patellofemoral joint forces more so than
single leg squats [41] and ACL reconstructed patients are prone to
developing patellofemoral pain [40,42].
Both squats and open chain knee extension have been
incorporated early as part of an ‘accelerated’ program post surgery.
[43] Although this current study has shown that these activities lead
to altered kinematics in the ACL-deficient knee care should be exercised
when timing the initia- tion of both exercises post ACL surgery,
especially post hamstring recon- struction where the graft fixation is
less secure. This applies particularly
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when prescribing wall squats, as in addition to increasing ATD, wall
squats did result in greater internal rotation than do seated extensions,
al- though this difference was not shown to be significant (p > 0.05). As
clini- cians we need to keep in mind that according to early
findings in sacrificed Rhesus monkeys, at three months post-surgery
the tensile strength of a patellar tendon graft is only 26% of the
contralateral side [44]. It is possible that it is not the distinction
between open and closed chain that makes exercises safe and our
findings cannot be generalized to open and closed chain exercises.
Tagesson et al. [45] for example com- pared two open chain exercises
5 weeks after ACL reconstruction and found that seated knee
extensions produced significantly more ATD than straight leg
raising (SLR). Kvist [46] has reinforced the importance of selecting
safe rehabilitation exercises that avoid excessive ATD espe- cially early
post surgery.
While considerable research has investigated the safety of exer-
cises based on their likelihood to cause ATD, further research needs
to explore the potential of exercise to cause other forms of abnormal
motion including rotation, valgus/varus, compression/distraction and
mediolateral shear. Similarly, poor neuromuscular control may also
promote altered knee joint kinematics that could disturb graft integ-
rity post-reconstruction. Hence, the question of whether the patient
has sufficient muscle control to perform the exercise precisely, re-
mains important in the choice of safe exercise post surgery.
Using our model we were able to directly measure very small tib-
ial movements during controversial dynamic exercises, albeit in the
context of the accepted errors associated with infra-red motion anal-
ysis methodology. We have drawn attention to the importance of un-
derstanding more fully the effect of each exercise on tibiofemoral
movement in order to protect the graft. We have questioned not
only whether certain exercises lead to ATD but also whether they en-
courage inappropriate internal rotation.
Weaknesses of this study include the aforementioned limitations
of the chosen motion analysis methodology, the small number of
subjects taking part and the absence of reliability testing. In addition
the eight participants all had chronic ACLD and had been treated
with physiotherapy prior to commencement of this study which
meant that they may have improved their dynamic knee stability
and may have behaved more like healthy controls. Hence,
generalization of these findings to other populations should only
be made with
caution. Future comparison of sub-populations is planned, including
a group untreated by physiotherapy.
In summary this study has shown that significantly more ATD
occurs during the single leg wall squat than the seated extension
and that greater tibial internal rotation occurs in ACLD knees as
compared to healthy knees during both exercises. We suggest that
exercises that promote alterations in knee joint kinematics should be
delayed until sufficient graft strength and neuromuscular control have
been achieved. In this way graft stretching and possibly later
development of OA may be minimized. We have found that exercise
impacts on knee joint kine- matics and we have highlighted the need
for critical appraisal of exer- cises prescribed following ACL injury
and reconstruction. In particular we have found that wall squats lead
to abnormal joint kinematics and should be prescribed only when
healing is adequate and dynamic con- trol has been established.
Conflict of interest statement
No author of this manuscript has any conflict of interest.
No funding was received for this study.
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