Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction

  • Mark C. Perry
  • Matthew C. MorrisseyEmail author
  • John B. King
  • Dylan Morrissey
  • Peter Earnshaw


Open kinetic chain (OKC) knee extensor resistance training has lost favour in ACLR rehabilitation due to concerns that this exercise is harmful to the graft and will be less effective in improving function. In this randomized, single-blind clinical trial OKC and closed kinetic chain (CKC) knee extensor training were compared for their effects on knee laxity and function in the middle period of ACLR rehabilitation. The study subjects were 49 patients recovering from ACLR surgery (37 M, 12 F; mean age=33 years). Tests were carried out at 8 and 14 weeks after ACLR with knee laxity measured using a ligament arthrometer and function with the Hughston Clinic knee self-assessment questionnaire and single leg, maximal effort jump testing (post-test only). Between tests, subjects trained using either OKC or CKC resistance of their knee and hip extensors as part of formal physical therapy sessions three times per week. No statistically significant (one-way ANOVA, p>0.05) differences were found between the treatment groups in knee laxity or leg function. OKC and CKC knee extensor training in the middle period of rehabilitation after ACLR surgery do not differ in their effects on knee laxity or leg function. Exercise dosages are described in this study and further research is required to assess whether the findings in this study are dosage specific.


Kinetic chain Exercise Quadriceps Strength training 



This study was supported by Action Medical Research, The Special Trustees of the Royal London Hospitals Trust and Technogym, UK. The authors would like to thank orthopaedic surgeons Messrs T. Bucknill, A. Davies, P. Earnshaw, M. El-Zebdeh, D. Goodier, M. Lamba, A. Lang-Stevenson, T.B. McAuliffe, D. Sweetnam and P. Thomas and physiotherapists M. Brown, W. Drechsler, J. Dredge, J. Jones, P. Knight, I. Man, B. Paton, R. Vauhnik and M. Yeboah for their support of this study.


  1. 1.
    Anderson M, Foreman T (1996) Return to competition: functional rehabilitation. In: Zachazewski J, Magee D, Quillen W (eds) Athletic injuries and rehabilitation, chap 13. Saunders, Philadelphia, pp 229–261Google Scholar
  2. 2.
    Arms SW, Pope MH, Johnson RJ, Fischer RA, Arvidsson I, Eriksson E (1984) The biomechanics of anterior cruciate ligament rehabilitation and reconstruction. Am J Sports Med 12:8–18Google Scholar
  3. 3.
    Augustsson J, Esko A, Thomee R, and Svantesson U (1998) Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. JOSPT 27:3–8Google Scholar
  4. 4.
    Beynnon BD, Fleming BC (1998) Anterior cruciate ligament strain in-vivo: a review of previous work. J Biomech 31:519–525Google Scholar
  5. 5.
    Blackburn JR, Morrissey MC (1998) The relationship between open and closed kinetic chain strength of the lower limb extensors and jumping performance. JOSPT 27:430–435Google Scholar
  6. 6.
    Booher LD, Hench KM, Worrell TW, Stikeleather J (1993) Reliability of three single-leg hop tests. J Sports Rehabil 2:165–170Google Scholar
  7. 7.
    Brosky JAJ, Nitz AJ, Malone TR, Caborn DN, Rayens MK (1999) Intrarater reliability of selected clinical outcome measures following anterior cruciate ligament reconstruction. JOSPT 29:39–48Google Scholar
  8. 8.
    Bynum EB, Barrack RL, Alexander AH (1995) Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction—a prospective randomized study. Am J Sports Med 23:401–406Google Scholar
  9. 9.
    Clark NC, Gumbrell CJ, Rana S, Traole CM, Morrissey MC (2003) Intratester reliability and measurement error of the adapted cross-over hop for distance. Phys Ther Sport 3:143–151Google Scholar
  10. 10.
    Flandry F, Hunt JP, Terry GC, Hughston JC (1991) Analysis of subjective knee complaints using visual analogue scales. Am J Sports Med 19:112–118PubMedGoogle Scholar
  11. 11.
    Gaunt BW, Curd DT (2001) Anthropometric and demographic factors affecting distance hopped and limb symmetry index for the crossover hop-for-distance test in high school athletes. JOSPT 31:145–151Google Scholar
  12. 12.
    Grana WA, Muse G (1988) The effect of exercise on laxity in the anterior cruciate ligament deficient knee. Am J Sports Med 16:586–588Google Scholar
  13. 13.
    Henning CE, Lynch MA, Glick KR (1985) An in vivo strain-gauge study of elongation of the anterior cruciate ligament. Am J Sports Med 13:22–26Google Scholar
  14. 14.
    Hooper DM, Morrissey MC, Drechsler WI, Morrissey D, King JB (2001) Open and closed kinetic chain exercises in the early period after ACL reconstruction: improvements in level walking, stair ascent and descent. Am J Sports Med 29:167–174Google Scholar
  15. 15.
    Jaureguito JW, Paulos LE (1996) Why grafts fail. Clin Orthop Relat Res 325:25–41Google Scholar
  16. 16.
    Kennedy JC, Roth JH, Mendenhall HV, Sanford JB (1980) Presidential address. Intraarticular replacement in the anterior cruciate ligament-deficient knee. Am J Sports Med 8:1–8Google Scholar
  17. 17.
    Kohn D, Rose C (1994) Primary stability of interference screw fixation—influence of screw diameter and insertion torque. Am J Sports Med 22:334–338Google Scholar
  18. 18.
    Kurosaka M, Yoshiya S, Andrish JT (1987) A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med 15:225–229PubMedGoogle Scholar
  19. 19.
    Maitland GD (1991) Peripheral manipulation, 3rd edn. Butterworth-Heinemann, OxfordGoogle Scholar
  20. 20.
    Mikkelsen C, Werner S, Eriksson E (2000) Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow up study. Knee Surg Sports Trauma Arthros 8:330–342Google Scholar
  21. 21.
    Morrissey MC, Hudson ZL, Drechsler WI, Coutts FJ, King JB, McAuliffe TB (2000) Correlates of knee laxity change in early rehabilitation after anterior cruciate ligament reconstruction. Int J Sports Med 7:529–535Google Scholar
  22. 22.
    Morrissey MC, Hudson ZL, Drechsler WI, Coutts FJ, Knight PR, King JB (2000) Effects of open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament reconstruction. Knee Surg Sports Trauma Arthrosc 8:343–348Google Scholar
  23. 23.
    Noyes FR, Mooar LA, Barber SD (1991) The assessment of work-related activities and limitations in knee disorders. Am J Sports Med 19:178–188Google Scholar
  24. 24.
    Palmitier RA, An K, Scott SG et al (1991) Kinetic chain exercise in knee rehabilitation. Sports Med 402–413Google Scholar
  25. 25.
    Prentice WE (1994) Closed-kinetic chain exercise. In: Prentice WE (ed) Rehabilitation techniques in sports medicine, 2nd edn. Mosby, London, pp 98–107Google Scholar
  26. 26.
    Queale WS, Snyder-Mackler L, Handling KA, Richards JG (1994) Instrumented examination of knee laxity in patients with anterior cruciate deficiency—a comparison of the KT-2000, Knee Signature System, and Genucom. JOSPT 19:345–351Google Scholar
  27. 27.
    Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF (1993) Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg 75A:1795–1803PubMedGoogle Scholar
  28. 28.
    Shelbourne KD, Klootwyk TE, DeCarlo MS (1992) Update on accelerated rehabilitation after anterior cruciate ligament reconstruction. JOSPT 15:303–308Google Scholar
  29. 29.
    Shelbourne KD, Nitz P (1992) Accelerated rehabilitation after anterior cruciate ligament reconstruction. JOSPT 15:256–264Google Scholar
  30. 30.
    Staubli HU, Jakob RP (1991) Anterior knee motion analysis—measurement and simultaneous radiography. Am J Sports Med 19:172–177Google Scholar
  31. 31.
    Steinkamp LA, Dillingham MF, Markel MD et al (1993) Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 21:438–444Google Scholar
  32. 32.
    Witvrouw E, Lysens R, Bellemans J, Peers K, Vanderstraeten G (2000) Open versus closed kinetic chain exercises for patellofemoral pain—a prospective, randomized study. Am J Sports Med 28:687–694PubMedGoogle Scholar
  33. 33.
    Yack HJ, Collins CE, Whieldon TJ (1983) Comparison of closed and open kinetic chain exercise in the anterior cruciate ligament-deficient knee. Am J Sports Med 21:49–54Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Mark C. Perry
    • 1
  • Matthew C. Morrissey
    • 1
    Email author
  • John B. King
    • 2
  • Dylan Morrissey
    • 1
  • Peter Earnshaw
    • 3
  1. 1.Division of Applied Biomedical Research, GKT School of Biomedical SciencesKing’s College LondonLondonUK
  2. 2.Academic Department of Sports Medicine, Queen Mary CollegeUniversity of LondonLondonUK
  3. 3.Guy’s and St Thomas’ NHS TrustLondonUK

Personalised recommendations