Ought to we carry out open kinetic chain workout routines after ACL reconstruction? Present analysis suggests we should always. Nonetheless, be sure to perceive the science.
Right here’s how we use OKC knee extension at Champion.
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#AskMikeReinold Episode 264: Open Kinetic Chain Knee Extension After ACL Reconstruction
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Present Notes
Transcript
Scholar:
So Dave from Instagram asks, “I at all times take pleasure in your on-line content material and recognize your strategy to PT. I used to be questioning if I may ask you a query that has give you my workers? Do you incorporate open chain knee extension workout routines along with your ACL sufferers and when do you begin? When do you begin to load an open chain knee extension train, any parameters you incorporate?”
Mike Reinold:
Superior, good things, Zack. So Dave, nice query. I used to be actually enthusiastic about this query, as a result of I feel Dave nailed it. So I feel what’s occurring, identical to all the things else, there’s lots of buzz on-line about this and I feel as we get to a tradition of social media the place all people simply likes to debate issues on a regular basis, I feel we at all times simply hear bits and items of this. However I feel what’s actually occurring now could be we had two nice items to the literature in final not even 12 months.
Mike Reinold:
There’s a commentary from Lynn Snyder-Mackler in JOSPT, the tip of final 12 months, that talked about utilizing open kinetic chain knee extension after ACL reconstruction and saying that we have to do it. And her large factor was it’s protected, it’s efficient, and it’s one thing that we should do with a view to get energy again. I feel what it was lacking although, like Dave sort of says there, is any tips. And I feel lots of people may take that the fallacious approach, proper? Like the place you may simply say, “Wow, Lynn Snyder-Mackler, she’s prolific with ACL analysis. She’s so good, she’s so nice. She’s saying we have to loopy, we have to go heavy open kinetic chain knee extension.” It was too broad.
Mike Reinold:
So Kevin Wilk only in the near past, within the Worldwide Journal of Sports activities Bodily Remedy, simply sort of printed one other one. It mentioned he sort of agrees with Lynn, however that we’ve to watch out. We simply can’t blindly go blasting away with open kinetic knee extensions. However once more, I don’t assume Kevin’s paper had parameters both. So let’s speak about that. Who needs to begin this one off about … Clearly the query is, can we do open kinetic chain knee extension workout routines after which let’s attempt to set up on this episode possibly the parameters that use at Champion, that are very analysis primarily based, however who needs to begin off?
Dave Tilley:
I imply, I’ll as a result of I are inclined to get into the warmth of battle on social media with these, and I feel individuals actually take a black and white strategy to those. They both, “I don’t do it as a result of the physician says I can’t or I’m taught that I shouldn’t as a result of college.” I positively have advanced the previous, I don’t know, 5, 10 years in my ideas as a result of I attempted to dive into the literature and see if there’s something, something apparent in anterior tibial translation which is at all times the argument that you simply’re placing further stress on the ACL by going that 30 to zero vary of movement. I’m struggling to search out one thing concrete to actually pull me again. That doesn’t imply I’m being aggressive and doing 50 pound knee extensions two weeks after surgical procedure.
Dave Tilley:
So, in my head, I are inclined to get a pair weeks out of surgical procedure and let issues heal down, particularly that anterior knee. I’ll do some, possibly, isometrics. I talked to Eric [Meira 00:06:01] about this. We talked about this lot, doing a little isometrics to let the anterior knee sort of get accustomed to a stress on it. After which I love to do some simply open chain knee extensions, that means sit on the fringe of the desk, if they’ve the vary of movement … Normally at two weeks out, they’ve 90 levels. In order that’s after I really feel snug doing it. I’m actually not going to pressure it in the event that they’re nonetheless struggling vary of movement. So vary of movement is a checkbox too, proper? Swelling’s coming down, vary of movement, ache is down. I’ll provoke it possibly with lively movement, possibly gentle ankle weight, after which I’ll progress from there.
Dave Tilley:
However, if I keep in mind from Kevin’s article and simply speaking from individuals typically, you bought to observe the graft too, proper? The patellar versus a hamstring graft goes to be very totally different in how I deal with them. Hamstring grafts, I am going somewhat bit much less aggressively as a result of it’s a soft-tissue graft and isn’t a bone interface attaching to the femur or the tibia. So I don’t wish to stretch out the hamstring by placing somewhat further stress by way of it. A patellar tendon and a quad tendon, I’ll most likely be somewhat bit extra aggressive than a hamstring. And for a cadaver, which I very hardly ever see, I don’t even … I have a tendency to simply sort of draw back for some time and possibly even wait six weeks, as a result of I simply don’t belief cadavers typically. Possibly even wait 12 weeks. I don’t know if that’s …
Mike Reinold:
Yeah, and even you simply citing the totally different grafts I feel is one thing that’s lacking. Should you simply take Lynn’s paper simply in and of itself, it’s like, “Do lots of open knee extensions, and do it heavy, and do it with all people.” Proper? And it was nearly like that we’re loopy if we’re not doing that. After which Kevin was nearly attempting to provide somewhat bit extra parameters that as you begin attending to terminal knee extension you set super quantity of pressure on the patellofemoral joint, on … Should you simply had patellar tendon graft, proper? And even any pressure of the ACL, it comes all the way down to, does it matter sort of factor? I feel it’s very clear.
Mike Reinold:
One fast query have for Diwesh, and we don’t need to get into this somewhat bit right here, however Dewey … Oh, I forgot to introduce all people, by the way in which. I simply completely remembered that. However anyway, Dewey, how many individuals in our gymnasium do open kinetic chain knee extension for quad strengthening?
Diwesh Poudyal:
None, as a result of we don’t have a viable [inaudible 00:08:11]. I get the query although, proper? I feel is it a needed train, no less than from the efficiency realm? In all probability not. Is it a possible train that we are able to use, the place you sort of goal somewhat bit extra like quad hypertrophy and isolate quads somewhat bit extra? Positive, yeah, nice choice.
Mike Reinold:
Proper, proper. I agree. That may be a nice choice too, however there’s so some ways to get quad strengthening, that I feel that’s an enormous a part of it, that all of us do it. So let’s attempt to set some parameters, proper? Let’s get all people. We’ll have a Champion consensus assertion. Poof. Let’s get this printed, proper? Consensus assertion right here. So first consensus right here. Will we all use open kinetic chain knee extension after ACL reconstruction? All in favor?
Lenny Macrina:
Sure, sure.
Mike Reinold:
So all of us agree you should utilize open kinetic chain knee extension. When must you begin? Lenny, would you wish to suggest two weeks as soon as they’ve 90 levels of knee flexion?
Lenny Macrina:
Sure. I feel good vary of movement, minimal ache, incisions therapeutic. Once more, graft alternative goes to play into my … Not less than in my head, I’m an enormous patella tendon man. So I see lots of hamstrings as a result of that’s what they do in Boston. However I feel two weeks most likely on the earliest simply to let issues sort of settle down and never stress that anterior knee. And such as you talked about, the [inaudible 00:09:38] joint stresses.
Mike Reinold:
All proper, so we’ll say we begin someplace, two, three, possibly even 4 weeks if we’re attempting to go somewhat slower on anyone else, proper? However we’ll say we begin two weeks. All in favor?
Lenny Macrina:
Yep.
Mike Reinold:
Proper. I used to be proper. So we begin at [2-E 00:09:54]. Ought to we begin at 90 to 40? Ought to we cease at 40? I’m going to begin and say sure. Does anyone wish to say we should always instantly begin going to zero?
Lenny Macrina:
I’d say we are able to begin it there and simply see how the knee responds, and particularly in case you’re going to do it earlier, and also you wish to check issues out, sure. If you wish to purchase time, that earlier time, and do it, I’d say sure.
Mike Reinold:
So that you get some good thing about open kinetic chain knee extension, however we’re minimizing pressure proper because the graft is beginning to develop into susceptible, or actually extra susceptible most likely.
Lenny Macrina:
And that final 30 levels of open chain, that 30 to zero, 40 to zero, is once more, when essentially the most stress is on the patellofemoral joint.
Mike Reinold:
Proper. So extra stress on the ACL, extra stress on the patellofemoral joint. In all probability extra stress on the tendon, too, as we get to that time. So a number of issues. So we’ll 90/40. Will we begin loading open kinetic chain knee extension, proper? We positively wish to load it, proper? So we do a progressive resistance factor. When do you begin going all the way in which to zero?
Dan Pope:
Six to eight weeks most likely.
Mike Reinold:
Oh, on common, proper? However what if anyone’s at 4 weeks they usually have full vary of movement, no ache. They’ll do it simply, lock out that knee. Would you begin it with no weight?
Dave Tilley:
Yeah, most likely no weight [crosstalk 00:11:13].
Lenny Macrina:
I do.
Mike Reinold:
So that you wish to begin it with no weight. So possibly you’re doing 90/40 with the resistance, however then you definitely’re doing all of it the way in which as much as zero with no weight?
Dave Tilley:
As a result of this particular person most likely additionally doing, if they’ll weight bear, they’re most likely doing zero to 45 shut chain. In order that they’ve experienced-
Mike Reinold:
Positively, proper. Positively. Yeah, no, I completely agree that they’re going to quad strengthening they usually’re going to get terminal knee extension in different methods too, proper? So it seems like we begin 90/40, we’ll begin loading 90/40, after which we’ll open up the window to zero with no load initially, after which slowly load it, proper?
Dave Tilley:
Proper.
Mike Reinold:
Does anyone assume we must be doing max effort open kinetic chain knee extension? All the way in which absolutely straight like on a machine, for instance, like we don’t even have at Champion? Is that … Are you aware what I imply, like that’s good, however I feel that was one of many issues large issues in Kevin’s article. He prompt that we should always keep away from that for six to 9 months. So early, aggressive … That’s aggressive although, Len, I see your face. Open kinetic chain knee extension all the way in which to zero.
Lenny Macrina:
Yeah, yeah.
Mike Reinold:
Like on a machine, like as heavy as you may. And, to me, I feel that was the direct assertion that Lynn’s article didn’t have there. I feel what he’s saying is like, “Yeah, go loopy, load it 90 to 40, load it as much as zero, however don’t load it aggressively for six to 9 months all the way in which as much as zero.”
Lenny Macrina:
The one factor I don’t agree with that, I assume is lots, is I do know in Birmingham, and in different places, in an outpatient facility … We don’t have it, however a Biodex is three months out of surgical procedure to check quad and hamstring energy. That’s a max effort open chain full vary of movement.
Mike Reinold:
However I feel there’s a distinction between doing it as soon as versus doing each day or thrice every week.
Lenny Macrina:
Possibly. I imply …
Mike Reinold:
I do know what you’re saying although.
Lenny Macrina:
I simply don’t know why at six to 9 months we are able to’t do it. Like the place within the literature is that this? What’s the research?
Mike Reinold:
I imply, you’re by no means ever, ever, ever going to have a research that tells you the reply.
Lenny Macrina:
In all probability not. I simply don’t know the place it initially got here from? What’s the thought? What? The anterior tibial translation and the place is that’s from? I’m lacking it. There’s something on the market, like from the ’80s or early ’90s.
Mike Reinold:
That is what Kevin put in his paper, however you’ve gotten unopposed anterior tibial pressure as a result of the hamstrings will not be concerned in open kinetic chain knee extensions. So you’ve gotten unopposed anterior pressure, you’ve gotten dramatic in crease in patellofemoral stress as you get going there. It’s lots tougher in there at that terminal knee vary of movement. I feel these are his two large issues. He’s not saying don’t do open kinetic chain knee extension with weight, he’s saying don’t attempt to max out on it for six to 9 months. I sort like his level, proper?
Mike Reinold:
I like these two papers collectively, proper? As a result of I feel Lynn’s attempting to say we shouldn’t be afraid of this, and I fully agree with that. I feel she did an important job along with her paper. And I like how Kevin’s saying you may’t say … I feel what’s Kevin attempting to say is you may’t say that to college students and early profession professionals as a result of they’re going to go bananas. They’re going to take that too far and he’s attempting to say, “Whoa, there are some parameters in it.”
Mike Reinold:
So I assume that’s the one factor. Anyone else wish to bounce in on max effort loading with open kinetic chain knee extension, when can we get to that? Dan?
Dan Pope:
I used to be simply going to say, whoever does a 3 rep max knee extension? When does that ever, ever occur?
Mike Reinold:
That’s a very good level. That’s a very good level.
Dan Pope:
It appears sort of ridiculous to me. So I feel it’s sort of difficult to say, “Heavy, heavy, heavy.” What the heck does that imply? If I’m doing units of 10, am I ever loading heavy sufficient, even when I’m going to failure? I assume, such as you mentioned, I don’t assume we’ll ever know, however I simply don’t know when in a coaching program you’d be doing below, let’s say, 5 repetitions in knee extension. Simply don’t assume that’s the place I’d wish to get nearly all of my energy from.
Mike Reinold:
That’s truly a really stable level. However once more, this isn’t a knock in direction of Lynn’s paper, however there’s no steering with that. She was simply saying we have to do it and we have to do it heavy. what I imply? So Dan, you assume that’s commonsense, I feel lots of us assume that’s commonsense. However I simply surprise if not all people has the expertise you’ve gotten with that, that you simply understand how you’d try this. And I feel that was Kevin’s sort of level was sort go straightforward.
Dan Pope:
Yeah, persistence.
Mike Reinold:
Yeah. I imply, I don’t know the reply too, however I like what we do. I feel we do reasonable energy coaching all the way in which to zero with our open kinetic chain knee extension, however the majority of the energy we’re getting might be not knee extension, proper? Once more, we don’t also have a machine at Champion, so I imply, we’re doing it with ankle weights. In order that tells you, I imply, I feel we’ve good outcomes, proper? So I don’t know. All proper, I nonetheless really feel like we have to nail that’s although. So what do you wish to suggest, Lenny, on how heavy you may go on knee extension and when are you absolutely cleared to do no matter you need?
Lenny Macrina:
I feel what Dan mentioned was going to be my subsequent one, was simply can they do eight to 10 reps and get a very good burn? And on the finish of that tenth rep, are they feeling a very good burn of their muscle that they’ll’t do an eleventh rep or twelfth rep? That’s, to me, a very good parameter of two, three units of that someplace of their program. However they’re additionally squatting and deadlifting and lunging and all the things else. Individuals don’t assume we’re simply speaking about open chain stuff. That’s constructed into this system to isolate the quads, however then we additionally get the quads in different workout routines. Simply wish to be sure individuals perceive that.
Mike Reinold:
Proper. And this is a wonderful, once more, glorious use of one thing like blood circulation restriction the place we are able to do an train with much less load as a result of we’re attempting to guard stuff. I feel Lynn’s paper was glorious as a result of it’s attempting to inform individuals we are able to’t be afraid of open kinetic chain. It’s not unsafe, it’s not much less useful, proper, as a result of quad energy’s useful. So she made nice factors. I feel Kevin’s paper truly had glorious factors too, the place it was like, “Sure, however it’s a must to be good with the way you’re prescribing that.”
Mike Reinold:
Let me attempt to summarize. So sure on open kinetic knee extension. We often begin about week two simply to let the knee heal down, let the incision heal somewhat bit, be sure they’ll get some … about 90 levels of knee flexion, that is smart. We’ll begin 90 to 40 for somewhat bit, possibly like a pair weeks or so simply to sort of get issues going. However then we’ll open it as much as zero. We’ll begin loading 90 to 40, proper, and sort of preserve the load 90 to 40 initially, however then slowly begin opening up that window.
Mike Reinold:
So I’d say most likely, what, week 12 possibly? Three months out or so, they’re most likely doing no matter you are able to do with ankle weight sort issues with open kinetic chain knee extension all the way in which as much as zero fairly simply. In all probability from month three to possibly month six to sort of use Kevin’s issues, we slowly improve the load on that if you’d like. However we’re most likely avoiding max till we’ve full graft therapeutic and all the things, proper? Like a max effort open kinetic chain knee extension which I feel Dan’s level is we don’t want that anyway, proper?
Mike Reinold:
And Diwesh mentioned we don’t want that, so to Lynn’s level, sure, we want open kinetic chain knee extension, however there’s different issues we are able to extra safely do with aggressive weight, proper? Like the place you’ve gotten co-contraction of the hamstrings, you’re doing it in a closed chain style the place it’s somewhat bit extra protected. I don’t know, what do we predict? Is that good? Anyone, did we miss something?
Diwesh Poudyal:
The one factor I used to be going to go away off with was, no less than from the efficiency finish of issues, proper, after we begin eager about … As a result of the purpose about max effort was the one I used to be actually caught on, and I 100% agree with Dan, we wouldn’t load up a max effort bicep curl or a tricep extension for a set of three, proper? We don’t have strength-testing parameters for 3RM bicep curl or tricep extensions. Nevertheless it’s identical to the commonplace to load max effort with the fitting train alternative. You possibly can most likely take your ACL sufferers and take them to units of three, units of 5 on squats, actually check pressure strain for the decrease physique proper? As a result of ultimately they’ve obtained to get again to sport and all that stuff, however yeah, like a brilliant heavy max effort knee extension simply doesn’t make a complete lot of sense to me.
Mike Reinold:
Yeah, adore it. Yeah.
Dan Pope:
Like danger reward, what sort of data are you getting with a 3 rep max versus like a eight to 10 rep max? Is it actually value it to try this?
Mike Reinold:
Proper. Yeah, so once more, I feel you guys … It’s the identical factor. I feel that was possibly Kevin’s level with Lynn’s … I haven’t talked to Kevin about this, by the way in which, however simply assuming from studying it. I feel that was his level, was that we’ve to watch out. I, personally, as an educator, proper, all of us educate on-line. I’m increasingly more cautious of what I put on the market as a result of you don’t have any thought how a younger clinician goes to take it, proper? So it’s a must to be very cautious. I’m not kidding, you’re going to see some individuals on Instagram go bananas with knee extensions. They’ll hook up a sequence to a VW bug and attempt to do knee extensions and attempt to transfer the automobile. what I imply? Any individual’s going to try this on Instagram they usually’re going to say, “I learn this paper that mentioned to do it,” proper? So that you’ve obtained to watch out.
Mike Reinold:
Anyway, superior. All proper, nice episode. That was a very good one. I prefer it. We went somewhat over, however that’s good. It was value it, that was a very good one. When you have extra nice questions like that, hopefully we are able to shed some gentle. Possibly somewhat bit share our sensible expertise with what’s out within the analysis, I feel that’s sort of why individuals take heed to this podcast. However thanks once more, actually recognize it, Dave. Thanks for the nice query. Once more, you probably have one other query like that, please head to mikereinold.com, click on on that podcast hyperlink, and we’ll see you on the subsequent episode. Thanks a lot.
