The American Journal of Sports Medicine http://ajs.sagepub.com/ Open Kinetic Chain Exercises in a Restricted Range of Motion After Anterior Cruciate Ligament Reconstruction : A Randomized Controlled Clinical Trial Thiago Yukio Fukuda, Deborah Fingerhut, Viviane Coimbra Moreira, Paula Maria Ferreira Camarini, Nathalia Folco Scodeller, Aires Duarte, Jr, Mauro Martinelli and Flavio Fernandes Bryk Am] Sports Med 2013 41° 788 originally published online February 19, 2013 DOI: 10.117710363546513476482 The online version of this article can be found at http:/fa!s.sagepub. com/contenv41/4/788 Published by: (SAGE http:/ww.sagepublications.com On behalf of: A ‘American Orthopaedic Society for Sports Medicine ‘Aaaitional services and information for The American Journal of Sports Meaioine can be found at: Email Alerts: hitp/ajs.sagepub.comegi/alerts Subscriptions: hitp:/ais sagepub.com/subscriptions Reprints: http:/www sagepub.com/joumalsReprints.nav Permissions: http:/iwww sagepub.comjournalsPermissions.nav >> Version of Record - Apr 2, 2013, OnlineFirst Version of Record - Feb 19, 2013 What is This?Open Kinetic Chain Exercises in a Restricted Range of Motion After Anterior Cruciate Ligament Reconstruction A Randomized Controlled Clinical Trial Thiago Yukio Fukuda,*t PT, PhD, Deborah Fingerhut,! PT, Viviane Coimbra Moreira,! PT, Paula Maria Ferreira Camarini,! PT, Nathalia Folco Scodeller,' PT, Aires Duarte Jr, MD, Mauro Martinelli,? MD, and Flavio Femandes Bryk,! PT Investigation performed at irmandade da Santa Casa de Misericordia, Sdo Paulo, Brazil Background: Recent studies have shown that an early start of open kinetic chain (OKO) exercises for quadriceps strengthening in 2 full rango of motion (ROM) could increase anterior knee laxity after anterior cruciate ligament (ACL) roconetruction with floxor tendons. However, there ara no clinical trials that evaluated outcomes of OKC exercises in a restricted ROM for pain, function, ‘muscle strength. and anterior knee laxity at 1 year after surgery. Purpose: To determina if an ary start of OKC exercieas for quadriceps strength in a restricted ROM would promate a clinical improvement without causing increased anterior knee laxity in patients after ACL reconstruction, ‘Study Design: Randomized controllad clinical tral; Laval of evidence, 4 ‘Mothode: A total of 49 pationte botwoon 16 and 60 yeare of ago who underwent ACL. reconetruction with somitendinosus and gra: fila aogentis were randomly assigned to an early art OKC: (FOKC) exercise group ora late start OKC: (LOKC) exercise group. Tha OKC aroup (n = 25: mean age, 26 years) received a rehabiltation protocol with an early start of OKC (fourth week postoperatively) within a restricted ROM between 45° and 90°. The LOKC group (n = 24; mean age, 24 years) performed the same protocol with alate start of OKC exercises between 0° and 90° (12th week postoperatively). Quadriceps and hamstring muscle strength, 1 1-point ‘numerical pain rating scale (NPRS), Lysholm knee scoring scale, single legged and crossover hop tests, and anterior knee laxity Were measured to assess Outcomes at the 12-week, 19-week, 25-week, and 17-month postoperative folow-up (range, 13-24 months). Results: No aitference (P < .05) was noted between groups with respect to demographic data. Both groups (EOKC and LOKC) had a higher level of function and less pain at the 19-week, 25-week, and 17-month assessments when compared with 12 weeks postoporatively (P <.06). The EOKC group had improved quadricepe musolo etrength at tho 19-wook, 25-wook, and 17-month follow-up when compared with 12 weeks postonarativaly (P < 05); tha LOKC group showed improvement only at the 17-month postoperative assessment. However. the analysis between groups showed no difference for all pain and functional assessments. including anterior knee laxity (P > .08), Conclusion: An early start of OKC exercises for quadriceps strengthening in a restricted ROM did not differ from a late start in terms of anterior knee laxity. The EOKC group reached the same findings in relation to pain decrease and functional improvement when compared with the LOKC group but showed a faster recovery in quadriceps strength. The nonweightbearing exercises ‘seem appropriate for patients who have undergone ACL reconstruction, when utiized in a specific ROM. The magnitude of dif- ference in quadriceps strengtn between tne 2 renabiltation protocols was around 5%; however, his diflerence was not cinically significant, especially because both groups had equal function on the hop tests. Keywords: ACL; knee; reconstruction; renabiltation; exercise therapy Surgical reconstruction of the ruptured anterior cruciate therapy. In recent decades, several forms of ACL rocon- ligament (ACL) is a common orthopaedic knee surgery _struction have been discussed. The choice of the hamstring and is usually followed by 4 to 9 months of physical _ tendons as a graft has increased in popularity with the jus- tification of generating minor complications such as ante- rior knee pain and strength deficit of extension, although leading to a possible deficit of flexion."*"™"* ‘The American Journal of Sprts Medicine, Vol. 41, No.4 Dok 10 17 7ausasaostSyotBe ‘After surgery, graft healing is characterized by a process (© 2019 The Author) called ligamentization. During thie poriod, the graft will 788Vol. 41, No. 4, 2018 ‘undergo changes, becoming similar to intact ligament tis- ‘uo, and will bo especially vulnerable during the necrosis and rovarcnlarization stages ©! "Therefore, ono of the major challenges in the postoperative rehabilitation of ACL reconstruetion is muscle strengthening, especially the quadriceps muscles, without compromising the graft heal- ing process and thus avoiding an inerease in anterior knee laxity and possible damage to the articular cartlage.*”**#° Accelerated rehabilitation protocols after ACL recon struetion have been inercasingly used because they allow fan early range of motion (ROM) and weighthearing ax well asa faster return to normal function and sports activ- ity." Closed kinetic chain (CKC) or weightbearing exer- cises are widely used in these protocols because of their known effects of articular compression and knee stabiliza- tion.”"” However, eontroversies exist regarding the onset of open kinetic chain (OKC) exercises." Clinical and bio- mechanical studico have shown that nonweightbearing exercises may promote greater anterior tibial translation at specific angles of knee flexion, thereby increasing the graft tension." In contrast, some authors have shown that quadriceps strengthening in OKC exercises can pro- vide an improved muscle torque without damaging the nor- ‘mal laxity of the knee joint as well as favoring a return to preinjury levels.**? Heijne and Werner" showed that an carly start of OKC exorcisor after ACL reconstruction with a hamstring graft promotes greater anteriar knee laxity compared with a late start. However, Escamilla et al® and Fleming et al!® dem- onstrated that it is possible to perform OKC exereises for quadriceps strengthening without overloading the graft by providing a restricted IKOM, that is, performing quadn- ceps activation between 90° and 49° of knee flexion. Despite numerous studies showing the advantages and risks of adding OKC exoreisos during the rehabilitation of patients after ACL reconstruction, there is limited infor- mation concerning the appropriate time to introduce these exercises, the best manner to prescribe them in relation to the ROM in the sagittal plane, and the possible influence on anterior laxity. Thus, the purpose of this study was to determine whether an early start of OKC exercises using restricted ROM would promote a clinical improvement ‘without causing inoreased antorior laxity in pationte after ACT. reconstruction, MATERIALS AND METHODS ‘Study Design and Participants ‘A total of 64 pationte who had undergone an ACL reconstruc tion were evaluated between March 2008 and July 2011; how- ever, based on exclusion criteria discussed below. only 49 patients participated in this clinical trial and were Open Kinetic Chain Exercises After AGL Reconstruction 789 randomized into 2 groups: 2 patients in the early start ‘OKC (BOKC) group, and 24 participants in the lato start OKC (LOKE) group. Twn pationts in the ROKC group and 2 patients in the LOKC group did not complete the 25-week rehabilitation protocol. In addition, 5 patients in each group did not attend the 17-month follow-up (Figure 1). Among ‘those, 2 patients in each group had a graft failure and under- ‘wont a now surgical roconstruction. Finally, 18 patients in he BOKC group and 17 patients in the LOKC group were ‘oczzed at the longer fallow up, and only 1 patient in each ‘group did not return to the prvinjury activity level ‘The sample size estimation calculations were justified based on the change of anterior laxity between the injured limb and the contralateral limb. A 2.0-mm difference between limbs in the EOKC and LOKC groups and a corre- sponding standard deviation of 2.0 mm were considered to be clinically relevant“® It was determined that a sample size of 15 paticnte per group would be neccooary to detect the 20.mm difference with 80% power when « was set ‘equal to 05. Anticipating that we would lose 20% of partic- ipants enrolled during a longer follow-up (mean, 17 ‘months), we planned to enroll 25 patients in each group. ‘The patients were between 16 and 50 years of age and ‘were included if they had undergone an ACL, reconstruc- tion surgery. The study was carried out at a single treat- ment center, and patients were referred to our sector by tho orthopaodie surgoons of tho sports medicine group. Single-bundle arthroscopic reconstruction was performed in all cases with the 4-strand semitendinosus and gracilis, tendon autograft as well as partial meniscectomy if neces- sary. The surgery was performed using the nonanatomic transtibial technique, with 2 portals (anteromedial and anterolaterab, and fixation of the graft in the femoral tun- znel with a transverse pin (TLC, Proind, Cotia, SP, BR) and tho tibial tunnel with a washer lock serow (Arrucla den- teada, Prosintese, Cotia, SP, BR). Patients were excluded if they had a previous injury or sursery to either knee, hhad missed more than 10% of treatment sessions, had wultaneous fracture or a concurrent injury to the pos- F cruciate ligament, had other ligament injuries, had demonstr such as diahotes or rheumatoid arthritis, ar wore pregnant. Furthermore. the patients who had surgery to reconstruct the ACL with a patellar graft or contralateral flexor ten- dons were also excluded." All volunteers were informed about the procedures for ‘the study and signed informed consent documents written in accordance with National Health Council Resolution ENS 196/96. This otudy was approved by the inveatigating institution's Research Ethics Committee. ‘After determining the inclusion of the participants, ‘a single examiner was responsible for the administration *Addrocecomeapondance to Thiago Yuo Fukuda, PT, PRD, Santa Casa do So Paul, Soler do Fisotorapie, un Dr Condo Mota sr, 112, 01201-020, ‘So Paulo-SP, Braz (malt: hukudatOByahoo.com.. "physical Therapy Sector, Imandade da Santa Casa de Miserica, So Paulo, Braz. ‘onmopaecis and Traumatoiogy Department, marado da Santa Casa de Wisencordia, Sdo Paulo, raz ‘Tha authors declared that thy haw no confit of tretinoin and pcaion oft conrton790 Fukuda et at ‘Aasessed for eligibility (0-4) ‘ary Open Kine hain group (n=25) cowed aocted I ‘2a toiown 5) || Followup —— | 18 fol up (25) 181 low ap 24) i r 25k now ap (23) ‘Bek tow op 22) patna mse Foams weatment session: troament sessions — ——r ‘Tamofolow up (=I ‘Fm fotow uo (=17) + Spaterts bate “Somonsiestt| += Zot had cee + Fotis ha bee sugey ser r r FT Analyt 2) FY Anaya r28) Figure 1. CONSORT flow chart, including intention-to-treat (77) analysio. of all tests and questionnaires at 12 weeks, 19 weeks, 25 weeks, and 17 months after surgery. This examiner was blinded to the group assignment of the patients and did not participate in the intervention. ‘The assignment of Pationte in tho 2 groupe was porformed randomly wring aque and sealed snvrinpes enntaining the names af the troups: EOKC or LOKC. The envelopes were selected by 4 person not involved in this study. Intervention ‘The intervention protocol of the EOKC and LOKC groups had a duration of 25 weeks (approximately 6 months), ‘Tho paticnte from both groupe complotod 2 treatment coo sions por week, for approximately 70 aoasiona. All patients started the postoperative protocol between the first and second week after surgery. Both protocols have empha- sized an increase in ROM, lower limb strengthening, and balance control. Isometric CKC exercises for hip and knee strengthening started at the second postoperative week, followed by operative week. However, started quadriceps strength tonic knee extension) at 4 weeks postoperatively. restrict- ing the knee ROM between 90° and 45° of flexion. These exereises were performed in a knee extension macl with a lock for restricting motion. The LOKC group lized the same exercises only at 12 weeks after surgery, The American Journal of Sports Medicine ‘at a fall ROM, that is, between 0° and 90° of flexion, ‘Thuo, the rehabilitation protocol was exactly the camo for the 2 groupa of patients, with the anly difference being the onset of OKC activities. Partial weightbearing with crutches was performed for 2 weeks after surgery in patients from both groups. It is important to highlight that they did not use an orthotic brace to restrict ROM after surgery. The protocol applica to the EOKC and LOKC yroups is described in detail in Appendix 1 (available in the online version of thio artiele fat http /ajs sagepnh com/aupplemental/). Four therapists trained in the rehabilitation protocol for the study were responsible for all treatments. Evaluation ‘Muscle Strength. Muscle strength of the quadriceps and ‘hamstrings was evaluated by measuring the maximum iso- metric voluntary contraction using a handheld dynamonse- ter (Lafayette Instrument Co, Lafayette, Indiana).”? For ‘the quadriceps, the patient was asked to sit on the table, with arms held against the body and hips and knees at {90° and 60° of flexion, respectively.’ The dynamometer ‘was positioned 2 inches proximal to the lateral malleolus ‘on the anterior aspect of the tibia, and the leg was stabi- lized by an inelastic band. This band was placed to fix te dynamometer w the front face of Ube leg, being fixed ‘on the base of the table. For the hamstrings, the patient was in a prone position on tho table, with the knoe faxed at 30°. The dynamometer was placed 2 inches proximal to the lateral malleolus on the posterior aspect of the leg, being stabilized by an inelastic band. This band was fixed directly to the ground. During strength testing, we used % submaximum trials to famihiarize the patients with ‘each test position. This was followed by 3 trials with max- imum isometzic effort for cach muscle group. For data ‘analysis, the avorage valuos ofthe 3 trials with maximum. effort were used. Ten healthy volunteers (f men and 5 ‘women) were tested according to the protocol deseribed above for quadriceps and hamstring strength as a pilot study. The results indicated good and excellent reliability, with intraclass correlation coefficients (ICs) of 0.89 and 0.92, respectively. “Anterior Knee Laity. Anterior knee laxity was analyzed bby the Ralimotor (Aireant, Viota, California). Proviows studios have shown similar necuracy of this artheometor ‘when compared with the KT-1000 arthrometer." The patient was in a supine position on the table, with a cushion under the knee to stabilize the joint at 25° of flexion, The Rolimeter was fixed to the patient’s leg with a single adjustable ankle strap distally. It was positioned such wat_a curved proximal plate lay on the venter of the la. One of the examiner's handa was placed on thio, stabilizing the plate to the patella and thus fixing the femur. A metal stylus was then placed on the patient's tibial tuberosity. A Lachman test was then performed to ‘quantify the anterior tibial dislocation. This anterior dis- placement of the stylus could then be read directly from ‘the 2-mm calibrations on the shaft of the stylus.'* TheVol. 41, No. 4, 2018 ‘Open Kinetic Chain Exercises After AGL Reconstruction 791 ‘TABLE 1 Demographic Data of the Early OKC and Late OKC Groups" Barly OKC (n = 23) Late OKC (n = 22) P Value BMI, kgf? 52 +35 29+32 36 Injured limb Left 11a) yan) Bight 12.652) 13 (60) See Male 16 (70) 13 (60) Female 70) 9140) ‘Time between inyury and surgery, mo 143 = 184 wa si a Partial meniscectomy 12.652) 1045) ‘Time of follow-up, mo 165 = 38 2936 a “Data are expressed as mean * standard deviation orn (%). OKC, open kinetic chain; BMI, body mass index. Only those patients remain- sng atthe end of the intervention are included, examiner applied maximum manual force until the ante- rior end point was reached. Three measurements were per- formed on each side, and the average was obtained. Thus, the difference between sides was cousidered for dala analyzia, Pain and Function, An 11-point numerical pain rating scale (NPRS) was used to measure pain, where 0 corre- sponded to “no pain” and 10 corresponded to “worst imag- inable pain.” The patients rated their worst level of pain during the last week. The NPRS has been shown to be reli able and valid, with a minimum clinically important difter- fence (MCID) of 2 points for general knee pain, although we have not found specific values for AOL reconstruction." ‘Tho singlo-logged hop tost and erossover hop tost wore used a functional tests, according to the standardizat of a previous study.” Three measurements were per- formed for each test in both lower limbs, and the first was performed to familiarize the patient with the test. ‘The average of the last 2 measurements was used for final analysis. The performance of the surgically treated limb ‘was expressed as a percentage of the healthy limb. "The Lysholm kneo scoring seale was used to mearure function and symptoms ‘This scale is an R-item functional assessment tool with Portuguese language validation. The final result is expressed in a nominal and ordinal form, with a rating score of excellent (95-100 points), good (84- 94 points), regular (65-83 points), and bad (<64 points).** However, the MCID in functional status has not been established. Statistical Analysis Data wore analyzed with SPSS version 12.0 (SPSS Ine, Chicago. Hlinois). Descriptive statisties for demographic data and all outcome measures were expressed as means * standard deviations. Comparison between the groups was performed using an independent ¢ test for age, body ‘mass index, and time between injury and surgery to dever- imine whether the groups presented similar demographics, ‘The data for mucele strength (quadriceps and hamatring), anterior knee laxity, the single-legged and crossover hop tests, the NPRS, and the Lysholm knee scoring scale ‘were analyzed using a separate 2 x 4 (group by time) mixedemodel analysis of variance (ANOVA). The factor group had 2 levels (OKC and LOKO), and the repeated factor time had 4 lovols (12, 19, and 25 wooks as woll as 17 months after surgery). An intention-to-treat analysis ‘was performed using the last-value-carried forward ‘method to input values forall missing data, RESULIS Demographic Data ‘There was no statistically significant difference (P > .05) for age, height, body weight, body mass index, and time to surgery between the EOKU and LOKU groups (able 1), The mean follow-up of the last evaluation was 17 = 5 months (range, 19-24 months). Muscle Strength ‘Thoro was a statistically significant group-by-time interac. tion for the 2 x 4 mixed-mode! ANOVA for bath quadriceps and hamstring strength assessments (P = .004 and P = .039, respectively). Planned pairwise comparisons for quadriceps strength indicated that the patients in the EOKC group had improved strength at 19 and 25 weeks ‘after surgery and at 17 months when compared with 12 wrecks (P ~ .029, P ~ .009, and P ~< .001, respectively). ‘Tho same analysis showed that the pationts in the LOKC group presented a significant difference anly at the 17- ‘month follow-up (P = .041). The hamstring strength evalu- ation showed that compared with 12 weeks after surgery, both groups had improved strength only at the 17-month follow-up (P = .380 and .005, respectively). We did not find any between-group difference for quadricops and ham- string strength at 12, 19, and 25 weeks and al 17 months after surgery (P > .05) (Table 2).‘T92 Fukuda et at The American Journal of Sports Medicine TABLE 2 Outcome Measures After Surgery for the Barly OKC (n ~ 18) and Late OKC (n ~ 17) Groupo" ‘Time After Surgery 39 Weeks 10 Wook 25 Woskee 17 Menthe Quadriceps strength Barly OKC 812+ 11.0(781803) 91H 11.9088.3973) 94.1 + 12.088.5-99.7) 997 + 72 (903-108.1) Late OKC S162173(734908) $7.0 = 1951805935) «89.5 = 10.7 (844.946) 96.1 = 11.8,89.5-100.7) Hamstring strength Early OKC) 77.0+ 15.9(696-844) «825+ 13.5(76.0890) 84.5 + 14.47.8912) 912 + 145 844.980) Late OKC 805 *107(754856) STR = 1441843913) 87-4 + 16.0(70.8.950) 980 = 1238 92.1-108.9) Single-legged yp test eon Barly OKC S24 + 17.0(74.5.90.) 88.7 = 8.1 (648026) 023 + 81 (88.4062) 98.5 = 6.5 (05.5-1015) Late OKC. 793+ 1230734852) 81 10.1 (83.3-92.9) 949 © 67 (91.7.98.1) 96.9 + 7.9 89.6-1042) Crossover hop test, em Early OKC” 845 + 133 (783-90.7) 904 + 8.9 (862-946) 940 + 6.4(91.097.0) 988 * 6.5 (95.8:101.8) Late OKC B19 122761877) 87.0» 110¢81.7-92.3) 925 + 7.6 (689-90.1) 962 + 84 (922-1002) Lyshaln 0-100) Barly OKC 883 + 76 (848-918) 95.5 + 5.1 (98.1979) 95.8 * 49 (98.5-98.1) 965 * 4.7 (913982) Late OKC 393 * 9.0 (85.0955) 89 46(927971) 94.3 * 12.4 (884-1002) 99.0 = 48 (96.7-101.3) NPRS (0-10) Baily OKC 115100616 06 + 120012) 04 + 08 (00-08) 04+ 12-02t 10) Tate OKC ga 1804a9 09+ 110414 02+ 050004 01+ 0200.09) Anterior laxity, mm Barly OKC 27218 1019.35) 29+ 14235) 30+ 1524.26) 27+ 142183) Late OKC. 2621910735) 27+ 190836) 30+ 172248) 35+ 1sa64a ‘Data are expressed ae mean * standard deviation (05% confidence intorval). OKC, apen Kinet chain; NPRS, numerical pain rating seale, ‘Anterior Knee Laxity ‘Thore was no statistically significant group-by-time intor- action (P > .05); that is, no difference was found within and between groups for all evaluation times, indicating that an early start of OKC exercises did not increase ante- rior knee laxity (Table 2). At the 17-month follow-up, among the 18 patients who finished the study in the EOKC group, 7 (39%) presented anterior laxity between Band 5 mm, and 2 (12%) presented greater than 5 mm. Moreover, among tho 17 pationte who finished the study in the LOKC geonp, 10 (59%) presented anterior laxity botwoen 3 and 5 mm, and 2 (12%) presented greater than 5mm, Pain and Function ‘A significant group-by-time interaction was found for the NNPRS (P = .051), single-legged and crossover hop tests (P= .005 and P = ,003, respectively), and Lysholm scale @ ~ .004), Planned pairwise comparicono for the NPRS showed decreased pain in both the BOKC and LOKC groups at the 25-week and 17-month assessments when compared with the 12-week assessment (01

05) (Table 2). The results af the intention to treat analysis were consistent with the per-protocol analysis, providing evidence that the missing data had no influence on the overall results. DISCUSSION ‘Tho aim of this prospective, randomized, and evaluator Ilinded clinical trinl was ta evaluate whether an early start of OKC quadriceps exercises in a restricted ROM ‘would promote a clinical improvement without causing anterior knee laxity in patients after ACL reconstruction with flexor tendon grafts. ‘The principal findings of the present investigation were that the carly start of non- weighibearing exercises using a restricted ROM did not differ from a late start in termo of anterior knce laxity. Moreover, the FOKC group reached the same results for pain and function as did the LOKC group but presented fa faster quadriceps strength recovery. The magnitude of difference in quadriceps strength between the 2 rehabilita- tions protocols was around 5%; however, this difference ‘was not clinically significant, especially because both ‘groups had equal function un Uae hop ests "These findings are in discord with thoae of Heijne and Werner'™!® and Kvist and Gillquist® who showodVol. 41, No. 4, 2018 «a significant increase in anterior knee laxity in patients with a reconstructed hamstring tondon graft who por- formed carly OKC exercises when compared with late OKC exercises. This laxity probably occurred because of the early introduction of quadriceps exercises (approxi- mately 4 weeks postoperatively) in a full ROM. It is believed that the graft undergoes a remodeling process, {including necrosis, in the first few weeks after surgery, suggesting that the ACL graft might have its lowest mechanical otrength around 6 to 8 weeks, followed by a amentization process that ean last up tn 1 year ©1120: The present study demonstrated that nonweightbearing exercises can be confidently utilized at an early stage, if performed between a knee flexion of 90° and 45°. Several authors postulated that this ROM is safe to strengthen the quadriceps musele without anterior shear, that is, without tension to the geaft22049 Mikkeleen et al? aloo demonstrated the benefito of quadriceps strengthening in OKC exercises in an initial postoperative stage when compared with a specific CKC exercise program. The authors added weightbearing exer- cises without increasing anterior knee laxity. However, this study assessed patients with patellar tendon graft reconstruction Similar to previous studies;¢"*7*"" our provocal was based on controlled ROM, knee and hip muscle strongthoning, functional and neuromuscular control, son- sorimotor training, and sports activities for a total period of approximately 6 to 7 months. It is important to highlight that the same protocol was applied in both groups, except when starting the nonweightbearing exercises. ‘No postoperative laxity values were measured directly after the surgical procedures, meaning that information regarding how the surgery may have influenced anterior Ienoe laxity is not known, In addition, wo alao did not oval- uate preoperative laxity. This might be regarded as a limi tation of the study. Five orthopaedic surzeons experienced in ACL reconstruction were involved in the surgical proce- dures. Of these, 2 surgeons were more involved than the others by performing 70% of the reconstructions. The num- ber of surgeons may be considered a weakness of the study. However, the single-bundle technique for ACL reconstruc- tion was used in all cases. A strong point of the study is that the rehabilitation was performed at one outpationt rehabilitation sports clinic and supervised by nhvsical therapists with considerable patient rehabilitation experi ence after ACL reconstruction. We also performed all assessments at 4 different phases: 12 weeks, 19 weeks, 25 weeks, and 17 months after surgery. Based on thve obtained results, itis thought that qua cepo_atrengthening with OKC ‘exercises in a rcotricted ROM appears not to increase postoperative anterior knee laxity. These data should be confined to flexor tendon reconstruction and not to a patellar tendon or even dou- blebundle anatomic technique. However, it remains unclear how quickly the frequency and magnitude of quad- riceps activation can be increased without creating an increase in anterior knee laxity. Furthermore, a more 9pe- cifie asacooment of the ligament ticoue and lower limb Kinematics must be addressed in future studios Open Kinetic Chain Exercises After AGL Reconstruction 798 CONCLUSION A start of OKC oxereises at 4 weeks postoperatively for quad- riceps strengthening through a restricted ROM (90°-45") did ‘ot differ from a start at 12 weeks postoperatively in terms of anterior kneo laxity. The EOKC group reached the same ‘findings in relation to pain decrease and functional improve- nent when compared with the LOKC group but showed 1 faster recovery of quadriceps strength. However, all other ‘outcome measures, including functional hop tests, did not dif. fer between the 2 groups. The nonweightbearing exercises ‘seem appropriate for patients who have undergone ACL reconstruction, when utilized in a specific ROM. REFERENCES: 1. une AK, Holm | Fisbora MA, Jonson HK, StoonH. 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YW RE, Macona L, Gan EL, Dugas JM, Anarows JK Hocontaavan- {20019 he renabition of antoner erect igameont nica. / Orthop ‘Soorts Ps Ther. 212:4203:189-171 For reprints and permission queries, pleas visit SAGE's Web site at http:/waw.sagepub comjournalaPermissions. nav