Kij 4

REVIEW / SPECIAL ISSUE
Sports Orthop. Traumatol. 39, 368–377 (2023)

Ó Elsevier GmbH
www.SOTjournal.com
https://doi.org/10.1016/j.orthtr.2023.10.008
Summary REVIEW / SPECIAL ISSUE

The article highlights newer aspects
of strength training after knee trauma
that need to be considered in the
Fundamentals of
future. Recent findings on muscle
contraction (three-filament theory)
individual loading for strength
and the importance of eccentric
training for prevention and rehabili-
training after knee injuries
tation are discussed. The altered
central, spinal, and peripheral neuro- ⇑
Jürgen Freiwald a, , Sasha Javanmardi a, Thilo Hotfiel b, Martin Engelhardt b
muscular activation patterns will be Ludwig Rappelt a, Christian Baumgart a
addressed after knee trauma and a
University of Wuppertal, Department of Movement and Training
during eccentric muscle actions and Science, Wuppertal, Germany
their causes. Biomechanical refer- b
Center for Musculoskeletal Surgery Osnabrück (OZMC), Klinikum Osnabrück,
ences and psychological (anticipa- Osnabrück, Germany
tory) aspects are discussed after
knee trauma. In distinction to Eingegangen/submitted: 16.9.2023; überarbeitet/revised 16.10.2023; akzeptiert/accepted: 16.10.2023
strength training with healthy per- Online verfügbar seit/Available online: 11 November 2023
sons, concrete hints for strength
training and its load normative with
persons after knee traumas are given. Introduction systematic structure of training
Finally, newer developments, includ- [49].
ing improved sensor technology, are The training principles and the load
presented, and concrete advice is Strength training after knee inju- normative of strength training have
given on optimizing strength training ries, before and after surgeries of been developed over the past dec-
after knee joint injuries and surgery. the knee joints and the surrounding ades primarily through experiential
Keywords tissues (e.g., capsules, ligaments, knowledge; only in recent years, it
Knee joint – Strength training – Eccentric
muscle actions – sEMG – Biomechanics
tendons, muscles) has been a natu- has increasingly developed through
ral part of preventing and rehabili- training experiments with – mostly
Jürgen Freiwald et al. tating knee traumas for many healthy – athletes.
years [31]. Strength training serves Training principles and load norma-
Grundlagen der individuellen two purposes when rehabilitating tive of strength training have been
Belastungssteuerung im Kraft- knee injuries: enhancing overall fit- increasingly applied to subpopula-
training nach Knieverletzun- ness and improving specific sports- tions (Ill or injured individuals),
gen related abilities. It is essential to and it is uncertain whether the
consider the effect of strength training principles developed for
Zusammenfassung training on the injured tissue and healthy individuals can be used
Der Beitrag beleuchtet neuere Aspekte the level of strength needed to for strength training after knee
des Krafttrainings nach Knietraumen, restore sport-specific skills. Consid- trauma in the orthopedic field
die es in Zukunft zu berücksichtigen ering the extent of the damage and [11,39] (Table 1).
gilt. Thematisiert werden neuere Er- the particular sport is crucial when This paper aims to differentiate the
kenntnisse zur Muskelkontraktion engaging in strength training exer- strength training developed from
(Drei-Filament-Theorie) sowie die be- cises for rehabilitation [19–21]. sports and its load parameters and
sondere Bedeutung des exzentrischen Parts of musculoskeletal rehabilita-
Trainings für Prävention und Rehabili-
to adapt them to the conditions
tion in strength training are gen- after knee trauma. For this purpose,
tation. Eingegangen wird auf die eral training principles serving as
veränderten zentralen, spinalen und recent research on the structure
orientations for (all!) athletes and and function of the muscles and
peripheren neuromuskulären Aktivier-
ungsmuster nach Knietraumen und bei
coaches and the organization and newer biochemical aspects of the
368 J. Freiwald et al. Fundamentals of individual loading for strength training after knee injuries
exzentrischen Muskelaktionen sowie Table 1. Traditional load normatives in strength training.

deren Ursachen. Biomechanische Be- Training (Load) intensity Intensity of the individual stimulus
züge werden ebenso wie psycholo- (%1RM, %RM; VAS)
gische (antizipative) Aspekte nach Training (Load) duration Exposure time of a single stimulus or
Knietraumen besprochen. In Abgren- a series of stimuli
zung zum Krafttraining mit gesunden Training (Load) density Time ratio between load and
Personen werden konkrete Hinweise recovery phases
Training (Load) frequency Number of training sessions in a
zum Krafttraining und deren Belas-
cycle, e.g., per week
tungsnormative mit Personen nach Training (Load) volume Duration and number [repetitions]
Knietraumen gegeben. Abschließend of stimuli per training session
werden neuere Entwicklungen, u.a.
die verbesserte Sensortechnik, darges-
tellt und konkrete Hinweise zur Opti-
mierung des Krafttrainings nach activation of the muscles after knee the implementation of eccentric
Verletzungen und Operationen des trauma will be considered. training forms is that eccentric
Kniegelenkes gegeben. strength training significantly
Three filament theory, nervous reduces the likelihood of injuries
Schlüsselwörter activation, and eccentric muscle [32].
Kniegelenk – Krafttraining – Exzentrik – sEMG – actions
Biomechanik
The latest developments in muscle Strength training – Technical
physiology and nervous activation capabilities and load on an
provide more detailed explanations individual biological matrix
for eccentric muscle actions Recent advancements in strength
[18,26,48]. Recent research has diagnostics and monitoring of
demonstrated that eccentric muscle sports activities and training
actions demand lower levels of neu- enable the evaluation and valida-
romuscular activation to generate tion of training principles and load
equivalent force as other muscle normative effectiveness using
actions, leading to decreased miniaturized, cost-effective biome-
energy expenditure for the same chanical sensors. Optimizing the
level of force production [29– load monitoring leads to optimizing
30,32]. (strength) training and load con-
Already in 1999, we could show trol, especially for preventive and
that after knee trauma, peripheral rehabilitative purposes [4,7,14,
as well as spinal and central ner- 25,27–29,34,50].
vous factors are responsible for Strength training loads act as stim-
reduced neuro-muscular activation uli on an individual biological
[15]. Additional researchers corrob- matrix, leading to neuro-muscular
orated our prior research and built adaptations based on genetic pre-
upon its findings. They showed that conditions and transcripts (see
higher brain centers offer altered Fig. 1).
activation in different brain regions The challenges for coaches and
after knee injuries and surgery. therapists lie in the fact that a)
These findings must be considered athletes react to strength training
during rehabilitative strength stimuli in a highly individual man-
training focusing on eccentric mus- ner and b) in injured athletes, addi-
cle actions [36–37,44]. Another tional healing processes are at work
important reason for increasing that act in a highly individual man-
J. Freiwald et al. Fundamentals of individual loading for strength training after knee injuries 369
Figure 1
Strength training is a dynamic process with continuous feedback loops. The components of the system change over time, including
epigenetic adaptions, ranging from milliseconds (e.g., nervous system; proprioception) to years (e.g., connective tissue; bone).
ner depending on stimulus settings strengthening after injuries and played increased activities in par-
and individual conditions as well as surgeries. The muscles around the tially altered brain regions
injured tissue types (see Fig. 1). joint cannot voluntarily be maxi- compared to healthy controls, indi-
Fig. 1 displays various factors that mally activated, and muscle atro- cating a higher level of coordina-
impact muscle trainability. Among phy occurs even if the patients tion effort and higher energy
these factors, the individuality of perform strength training [14]. Less consumption after knee trauma [6].
strength training and the individual activation of the muscles after Barker et al. (2015) recently found
responsiveness of each athlete are injury and surgery depends on cen- that serum cytokines are enhanced
apparent. tral, local, and peripheral factors after ACL injuries, corresponding
such as inactivity, post-surgery with the strength of the quadriceps
Arthrogenic muscle inhibition, reduced activities, and healing muscle [1]. Moreover, joint effusion
altered central nervous system, aspects [42,44–46]. and swelling of the knee capsule
and biochemical aspects Patients with ACL injuries who also lead to inhibition of the sur-
Arthrogenic muscle inhibition show more significant asymmetries rounding muscles, mainly the anti-
(AMI) is a limiting factor in muscle and lower performance on the gravity muscles [14]. To influence
injured side (e.g., hop test) dis- this inhibition process, combining
strength training, anti- Selected aspects of rehabilitative frequency activation [Hz] necessary
inflammatory drugs, and physical strength training with injured for activating fast twitch muscle
therapy such as lymphatic drainage, persons fibers (FTx). Nevertheless, both
compression, or ice treatment is Knee trauma usually impairs the peripheral and central nervous acti-
essential to reducing joint effusion maximum force and the rate of vation and control of the muscles
and inflammation [44,46]. force development (RFD), a critical can be impacted. Severe knee inju-
Biochemical reactions can occur factor in developing explosive ries can diminish the CNS’s explo-
from injuries, healing processes or power for high-speed sports. On sive, high-frequency activation of
surgery, and strength training the one hand, explosive and maxi- muscles, which may not be fully
[5,40–41]. In rehabilitative mally powerful loads are necessary recoverable [2].
strength training, biochemical for sport-specific strength training; Therefore, not only maximum force
parameters can be collected, e.g., on the other hand, they are often is impaired after knee trauma, but
by blood, urine, and saliva tests. impossible with injured people due especially the rate of force develop-
Still, care must be taken to first col- to damage [39]. ment (RFD), which is one of the
lect an ‘individual baseline’ under Exercise selection is based on the essential parameters in explosive
low load and determine the deflec- individual, injury-related biome- force development in high-speed
tions of the measured parameters chanical load capacity and the sports.
under training loads [12]. sport-specific requirements. To effectively activate the FTx
Various measurements can be taken Depending on the injury and the fibers with explosive power, it is
to establish a reliable baseline for goals (sport-specific), primary recommended to utilize high resis-
training adaptations, including cor- objectives include regaining maxi- tance (weights) and maximum
tisol/testosterone ratios, adrena- mum strength, force increase slope, acceleration or heavy eccentric load
line, noradrenaline levels, reactive strength, and, in particu- training [16]. Both forms of exer-
Hemoglobin, CK, and urea levels. lar, coordinative control concerning cise are restricted to rehabilitative
Deficiency symptoms such as fer- a target sport [39]. It should be strength training of the injured
ritin and iron deficiency (and, in emphasized that rehabilitative limb to prevent further damage
rare cases, magnesium deficiency) strength training always includes from high biomechanical loads. As
should also be checked. Monitoring sensorimotor training (coordina- a result, low intensities and high
immune status indicators such as tion) and, therefore, cannot be con- volumes are often used during
free radicals and antioxidants is sidered and planned in isolation as training sessions. This approach
also recommended. By establishing a conditional skill [49]. affects the injured limb and the
a solid baseline, any deviations After analyzing EMG data, we found entire body, decreasing neuromus-
can be accurately interpreted about that knee injuries affect coordina- cular activation from the central
training adaptation [12]. tion and require muscle amplitudes nervous system [2].
The biochemical parameters can for movement throughout the body Exercise selection is, therefore,
provide valuable insights into an [2,14]. based on the individual, injury-
individual’s load, nutritional, and related biomechanical load capacity
resorption behavior. They are and the sport-specific require-
After an injury, it’s essential to
instrumental in assessing the sta- ments. This problem is evident in
exercise and train complex
tus of essential nutrients such as movements, not just individual all sports disciplines. On the one
vitamins, minerals, and trace ele- muscles, to achieve the same hand, explosive and maximally
ments. By analyzing these param- goals with altered coordination. powerful loads are necessary for
eters, one can better understand sport-specific strength training; on
an individual’s overall health and the other hand, they are often
well-being, training load, and Reestablishing muscle activation impossible due to damage. When
the effectiveness of strength amplitudes (lV) is comparatively choosing exercise, biomechanical
training [3]. simpler than restoring high- considerations must be made.
One example is the biomechanics of ventions should be tailored to the considering the possible impact of
the deep knee squat. Deep squats individual sensorimotor and psy- pain, fear, or insecurity on the
are essential for weight lifters but chological context, which influ- outcome.
lead to the highest biomechanical ences the planning and execution
loads on the knee joint (Cartilage, of movement actions [17,33], as
Conclusion and
Cruciate ligaments, Menisci, each trauma changes the subjective
Tendons). self-perception and, therefore, recommendations for future
Deep squats are prepared for years affects the planning, execution, rehabilitative strength training
in weightlifting, first without and and evaluation of movement after knee injuries
later with increasing weight load. actions [23–24,47] (Fig. 2).
In most sports, deep squats are not The anticipation of pain, fear, or In strength training for rehabilita-
necessary for training-specific insecurity can result in reduced tion, it’s essential to consider the
joint-angle-strength gains. This coordination, force production, latest research on muscle physiol-
makes them unsuitable for exercise, and explosive power, as well as a ogy, eccentric training, load char-
particularly during and after decreased rate of force develop- acteristics, new technology,
rehabilitation. ment [13] (Fig. 2). genetic adaptation, and psycholog-
Suppose an athlete is expecting to ical factors. Applying evidence-
Psychological and anticipating experience discomfort while under- based medicine and training to
aspects going a maximal strength test, enhance rehabilitative strength
Many factors influence whether an which could result in a decrease in training is crucial to optimizing
individual will return to sport after their exertion. The conventional strength training after knee injuries
this surgery. They include surgical strength training methods can pose [10,43]. In the future, the usual
details, rehabilitation, and social a challenge as the therapist relies load standards must be adapted to
and psychological factors [8–9]. on the maximum strength reading the unique requirements of rehabil-
After knee trauma, training inter- to devise the training plan without itative strength training (Table 2).
Figure 2
Implicit and explicit planning, planning, and execution of movement actions.
It is recommended to include bilitation, monitoring biochemical eccentric exercises reduce the risk
sensor-based monitoring in rehabil- levels to regulate physical strain of injury, especially to the ham-
itation, such as GPS, LPS, force and prevent overtraining may be string muscles and ACL [35]. Reha-
transducer, force plates, sEMG, and beneficial, and athletes should bilitative strength training should
electronic goniometer, to improve receive psychological support to prioritize complex movements that
training control and scheduling. reduce anxiety, uncertainty and mimic everyday activities and
Rehabilitative strength training enhance their motivation. Includ- sports rather than solely targeting
should be more personalized and, ing more eccentric strength train- individual muscles. The muscles of
in exceptional cases, involve ing after knee trauma is vital the non-injured limbs and trunk
genetic analysis. In high- when creating training schedules. should be trained more often with
performance sports, even in reha- Scientific studies have shown that explosive force development, as
Table 2. Extended load normatives in strength training after injuries.

Parameter Description/ General Comments Special comments for orthopedic
Units rehabilitation
Load intensity [1RM%]; [MRM%] For healthy and trained athletes, the Injured athletes should not
[Subjective single-repetition maximum is the first measure their single-repetition
Scales 0-10] choice. maximum due to pain and risk of
further injury. As a result, maximum
force measurement is not a valid or
reasonable option.
Load volume Number of For healthy and trained athletes, an It is important to gradually increase
repetitions [n] important parameter to consider is exposure and monitor for potential
Duration of the alignment of load intensity. stress reactions such as joint pain,
repetitions [s], hyperthermia, swelling, and joint
[min] effusion.
Numbers of [n] Number of sets; number and duration The frequency of exercise should
sets of neuromuscular activations gradually increase, taking into
account possible negative reactions
such as muscle soreness, joint pain,
hyperthermia, swelling, and joint
effusion.
Time under [s], [min] The recommended time under tension Due to the lower activability after
Tension for hypertrophy is 90-120 seconds. knee trauma (especially of the knee
extensors), a longer duration of
activation should be aimed for after
knee trauma
Type of load - Concentric, 1st movement phase = moving weight In orthopedic rehabilitation, it is
muscle action eccentric, 2nd movement phase = reversing important to practice the
isometric, movement alternation between concentric and
auxotonic, 3rd movement phase = return weight eccentric muscle action (movement
isoinertial and reversal) and to improve
isokinetic neuromuscular control during
eccentric movement.
Accentuated ATP; KP Accentuated metabolic range Depending on the requirements of
metabolic Anaerobic- the sports, different metabolic
range lactacid ranges can be targeted, particularly
anaerobic alactacid metabolism
(ATP; CK) and lactate metabolism
(anaerobic glycolysis).
Table 2 (continued)
Acceleration Force increase To achieve a higher movement speed, The advantage of performing
(Rate of force slope (RFDmax) the acceleration must be increased. strength exercises with low
development, [N/s], [m/s2] There are different types (Parameter) intensity, slow speed, and minimal
RFD) of RFD: weight is the reduced pressure on
[m/s] Average RFD or IES (Index of the healing tissue. However, the
Load Velocity Explosiveness) downside is the activation of
Time-Interval RFD predominantly slow-twitch fibers.
Instantaneous RFD The increase in force (acceleration
Peak or maximal RFD of masses/weights) is directly
Time to peak RFD inversely related to the mechanical
stress on muscles, tendons, and
cartilage.
Therefore, at the beginning of
rehabilitation, the acceleration of
resistance should be kept low.
Slow accelerations recruit
predominantly ST and FTA muscle
fibers.
Both when training on equipment
and with free weights, attention
must be paid to optimal technique,
regardless of the speed of
movement
Movement [m/s2] Holding - slow - fast - maximum fast Different accelerations during
reversal points movement reversal led to various
neuromuscular recruitments and
biomechanical loads.
Range of [°] The range of motion influences the Damaged or low-load joint areas
motion (ROM) time under tension at the same speed can be left out by restricting
of motion. certain joint angles.
The use of the entire ROM in
strength exercises can increase
joint mobility.
Load duration [s] Time under Tension of one single The frequency of exercise should be
(1) - single contraction [s] increased slowly, and possible
contractions adverse stress reactions should be
considered (muscle soreness, joint
pain, hyperthermia, swelling, joint
effusion).
Load duration [s] Time under Tension during repeated The frequency of exercise should be
(2) - repeated muscle actions (Total time [s]) increased slowly, and possible
contractions adverse stress reactions should be
(set; training considered (muscle soreness, joint
unit) pain, hyperthermia, swelling, joint
effusion).
Table 2 (continued)
Load density [s], [min] Recovery times between sets vary The duration of rest periods
Load frequency based on training status and training between sets in strength training
target. sessions is determined by various
factors, such as one’s current load
capacity, training condition, and
objectives. Recovery times might
need to be prolonged when working
with orthopedic patients due to the
healing processes and adjustments
to strength training. It is crucial to
ascertain individual recovery times
based on their specific load
capacity.
Recovery times [n/hours] The recovery time between training When training orthopedic patients
between [n/day] sessions varies for different levels of for strength, it is crucial to tailor
training [n/week] training. Untrained people need the frequency of the sessions to
sessions about 72 to 84 hours, strength- their current load capacity. This is
trained athletes about 48 hours, and because their healing processes and
highly trained athletes 24 to 48 adaptations to the training stimuli
hours. are parallel. Additionally, recovery
times between training sessions
may be prolonged.
Termination [n], [s], [min] Reaching the specified number of When strength training with
criterions VAS Protocols repetitions [n] or contraction orthopedic patients, special
Subjective duration [s], Failure to achieve the attention must be paid to the
perceptions and predetermined range of motion [0], technique of movement execution
protocols. Exhaustion - Loss of technique, Point and whether the patients
of Momentary Muscular Failure (PMF). experience pain.
Achievement of PMF is extremely During the initial phases of
dependent on patient motivation and rehabilitative strength training,
perception of pain. training up to PMF is not
recommended due to the high
biomechanical load and loss of
technique.
It is crucial to maintain a written
record of how orthopedic patients
perceive strength training and
reasons for discontinuation, if
necessary.
maintaining high-frequency activa- phatic drainage, compression, or Supervision. Sasha Javanmardi:

tion of the muscles by the central ice treatment therapies. Investigation, Visualization, Writ-
nervous system is of great impor- ing – review & editing. Thilo Hot-
tance [22,38]. fiel: Investigation, Writing –
CRediT authorship contribution
Attention must be focused on review & editing. Martin Engel-
reducing atherogenic and central statement hardt: Investigation, Writing –
nervous inhibitory processes review & editing. Ludwig Rappelt:
related to the injured joint. This Jürgen Freiwald: Conceptualiza- Writing – review & editing. Chris-
tion, Investigation, Writing – orig-
combines strength training with tian Baumgart: Conceptualization,
physical therapy focusing on lym- inal draft, Visualization,
Investigation, Writing – review & [8] J.A. Feller, K.E. Webster, Where are component and non-cross-bridge
editing, Supervision. we with return-to-sport testing component, Int J Mol Sci 20 (21)
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REVIEW / SPECIAL ISSUE

Sports Orthop. Traumatol. 39, 368–377 (2023)

Summary REVIEW / SPECIAL ISSUE

exzentrischen Muskelaktionen sowie Table 1. Traditional load normatives in strength training.

Table 2. Extended load normatives in strength training after injuries.

maintaining high-frequency activa- phatic drainage, compression, or Supervision. Sasha Javanmardi:

Available online at: www.sciencedirect.com

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