Open Kinetic Chain Exercises in a Restricted Range of Motion After Anterior Cruciate Ligament Reconstruction

Background: Recent studies have shown that an early start of open kinetic chain (OKC) exercises for quadriceps strengthening in a full range of motion (ROM) could increase anterior knee laxity after anterior cruciate ligament (ACL) reconstruction with flexor tendons. However, there are 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 determine if an early start of OKC exercises for quadriceps strength in a restricted ROM would promote a clinical improvement without causing increased anterior knee laxity in patients after ACL reconstruction. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: A total of 49 patients between 16 and 50 years of age who underwent ACL reconstruction with semitendinosus and gracilis autografts were randomly assigned to an early start OKC (EOKC) exercise group or a late start OKC (LOKC) exercise group. The EOKC group (n = 25; mean age, 26 years) received a rehabilitation 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 a late start of OKC exercises between 0° and 90° (12th week postoperatively). Quadriceps and hamstring muscle strength, 11-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 follow-up (range, 13-24 months). Results: No difference ( 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 postoperatively ( P < .05). The EOKC group had improved quadriceps muscle strength at the 19-week, 25-week, and 17-month follow-up when compared with 12 weeks postoperatively ( P < .05); the 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 > .05). 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 utilized in a specific ROM. The magnitude of difference in quadriceps strength between the 2 rehabilitation protocols was around 5%; however, this difference was not clinically significant, especially because both groups had equal function on the hop tests.