ACLR REHABLITATION: OKC VS.

CKC
ON AVERGAGE, ACLR patients show 28.5% deficit in quadriceps strength compared to un-involved LE at ~8
months post-op (attributed to diminished neuron recruitment and decreased motor unit firing frequency)

 Roos et al (2014) 13 month post-op ACLR exhibit average knee

extensor moments that are 17% smaller in involved LE compared to
uninvolved LE during a bodyweight squat
 Grindem et al (2016) every 1% decrease in quadriceps strength
relative to 90% of the opposite side = reinjury risk of 3%
 Sigward et al. (2018) 28.5% decrease has been attributed to frequent
compensatory strategies used by ACLR patients during CKC exercise
o interlimb compensation strategy: used around 3 months (shift to
un-involved leg)
o intralimb compensation strategy: used around 5 months (hip
dominant squat strategy which reduces the demand on the quadriceps)

Common belief is that OKC exercises cause increased strain on the ACL compared to CKC exercises as well
as increased joint laxity & anterior tibial translation…

 The ACL prevents anterior translation of the tibia on the femur in OKC
 The ACL prevents posterior translation of the femur on the tibia in CKC

Early Introduction of OKC in ACLR Rehabilitation:

 Tagesson et al. (2008) OKC vs. CKC in post-op ACLR found that OKC group demonstrated significantly
greater isokinetic quadriceps strength with no other functional differences in joint laxity noted between groups
 Mikkelsen et al. (2000) noted that the addition of OKC quadriceps training 6 weeks post-op ACLR resulted in
a significantly higher quadriceps torque without reducing knee joint stability at 6 month follow-up
 Mikkelsen et al. (2000) concluded that incorporating OKC exercises correlated to a significantly higher
percentage of athletes returning to PLOF earlier and at their same pre-injury competitive level
 Fukuda et al. (2013) compared early introduction of OKC extension at 4 weeks post-op and late introduction
of OKC extension at 12 weeks post-op.
o Early OKC: showed improvements in quadriceps strength at 19 week, 25 week, and 17 month follow
up
o Late OKC: only showed improvements in quadriceps strength at 17 month follow up
o No difference in anterior knee laxity between early and late OKC groups

Conclusions:
 BOTH OKC and CKC are appropriate for quadriceps strengthening following an ACLR  goal is to restore
quadriceps symmetry of involved side
 OKC strengthening is SAFE to perform in a limited ROM (45-90 degrees) starting at 4 weeks post-op with
adequate quadriceps control
 OKC exercises initiated after 6 weeks post-op can improve strength without adversely affecting the graft
 “Who’s Afraid of the Big Bad Wolf?” JOSPT Article (September 2020)
o OKC exercises post-ACLR are safe and only means to isolate the quadriceps muscles
 Things to consider before incorporating OKC knee extension into exercise programs for patients following
ACLR: resistance, graft type (HS > patellar), arc of motion, time frame from surgery, and type of patient
Abbey Hammann, SPT
University of Cincinnati 2023
July 15, 2022
 ACLR REHABLITATION: OKC VS. CKC
Pros
Similar ACL strain values with OKC knee extension
and CKC squats with low resistance loads
Note: mini-squats, sit-to-stands, and BW exercise are
common exercise prescriptions for patients following
ACLR
Walking on a level surface produces 355N of anterior
shear force on ACL whereas peak loading during a 90
degree dynamic knee extension for 12 repetitions of
maximal resistance produced 248N of anterior shear
force
(Walking  WB LE in 15-20 degrees of knee flexion as
the opposite foot approaches toe off)
Estimated that approximately 20-40% ligament strain
results in graft rupture  most activities with
rehabilitation range anywhere from 2-4% (including
OKC knee extensions)
No full range OKC knee extensions with significant
force 6-9 months following ACLR pending tissue
healing but low loads are safe and are even safer to use
from 90-40 degrees of flexion ROM
Abbey Hammann, SPT
University of Cincinnati 2023
July 15, 2022
Cons
Large quadriceps forces are required to perform the last
~15 degrees of OKC knee extension
OKC knee extension performed without adequate
quadriceps control can be harmful to graft due to
unopposed anterior shear forces regardless of number of
weeks post-op
If initiated too early, at an improper angle, or
inappropriate load, there is a risk of increased laxity of
new ligament  high loads from 40-0 degrees of knee
flexion can be harmful following ACLR or cause ACL
laxity in general
Anterior Knee Pain: PF joint reaction and compressive
forces are greatest between 50-0 degrees of knee flexion
in OKC compared to CKC (susceptible to injury during
heavily resisted OKC extension)
 ACLR REHABLITATION: OKC VS. CKC
References

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Abbey Hammann, SPT

University of Cincinnati 2023
July 15, 2022