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1980; 60:1602-1610.PHYS THER.Terry Malone, Turner A Blackburn and Lynn A WallaceKnee Rehabilitation

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Knee Rehabi l i tat ionTERRY MALONE MSTURNER A. BLACKBURN MEdand LYNN A. WALLACE MS

K ey Words:Exercise Therapy KneePhysical Therapy.

Although many knee rehabilitation programs exist,there are few laboratory-controlled studies comparingthe efficacy of these particular programs. Most programs, therefore, are based on clinical experience andempirical data. This article presents rehabilitationprograms we have found from clinical experience towork w ith many types of knee disorders. In our clinicswe treat several hund red patients with knee problemseach year, inasmuch as our practices are primarilyoriented toward orthoped ic sports medicine. The kneedisorders range from contusion to surgical reconstruction.Our programs are presented here in order of thevarious periods of rehabilitation. We have tried toemphasize general rehabilitation rather than specificstrength training because this article is directed to thephysical therapy practitioner rather than the athletictrainer. This article also describes the use of appliances often integrated into a comprehensive rehabilitation program.GENERAL GUIDELINES

Our rehabilitation p rograms, designed to deal withpathological conditions, are based on high repetitionand relatively low resistance. Following this p rincipleminimizes the stress placed upon the knee. In ahealthy knee, a low-repetition, high-resistance program has its benefits, but in many knee disorders thesupporting structures or articular surfaces often cannot safely handle the high resistance. Swelling anddiscomfort commonly result. The DeLorme1and Oxford2techniques are excellent for building strength innormalknees.Dr. Ken Knight's DAPR E also appearsto build strength quickly.3 But in our hands, theseprograms have irritated many of the knee problems.We believe that the critical factor in the success of anexercise program is to avoid causing swelling anddiscomfort while having the patient work to his maximum exercise tolerance.

Our knee rehab ilitation p rograms are also based onthe belief tha t if knee surgeryisperformed, the success

of that surgery is dependent upon a disciplined exercise program. This principle applies to programs notonly for the athlete but for the nonathlete. Kneemusculature cannot be expected to approach normalstrength without such a disciplined program. Manyknee programs have the potential of helping thepatient reach the goal of normal strength, but theirsuccess depends on discipline. It takes perseveranceto succeed.Our programs are designed to be done at home andto use equipment available to the patient, inasmuchas many of our patients live out-of-town. Also, ourprograms are designed to carry over from the hometo the hospital and back to the home again.Before designing a knee program, we carefullyevaluate the knee as outlined in the article in thisissue on evaluation. This evaluation provides a database for successfully designing and implementing anadequate rehabilitation program. A preliminary diagnosis is made as soon as possible after an acuteknee injury. This preliminary diagnosis assists therapists in designing and implementing the rehab ilitationprogram. The rehabilitation is begun as rapidly aspossible. Surgery, should it be performed, is doneearly because after 10 days the torn ligamentousstructures become very difficult to repair. Swelling inthe knee joint may not allow the surgeon to make adefinitive diagnosis immediatelysothat he can do thesurgery if necessary. Exercises can be used to decrease

the effusion or hemarthrosis in the knee and thusallow the knee to be examined more effectively. Often, exercises will decrease the swelling enough sothat the knee joint will not have to be aspirated.Chronic knee instabilities often require reconstruction. These procedures are normally more difficultand complex than acute injury repairs. The chronically involved knee will benefit from an exerciseprogram to the extent that the problem may be diminished through increased strength or flexibility.Even if the problem is not negated, at least theextremity will be better able to withstand surgery.The exercise programs vary depending on the problem and the condition ofthe patient.After surgery for acute or chronic problems, avigorous rehabilitation program must be undertakenwith the goal of rebuilding the strength of the involved extremity as well as the entire body. Theextremity must regain range of motion and function.The true test of rehabilitation is whether the patientcan return to the same level of function he had beforethe injury. The debilitation of the body during andafter major knee surgery and the subsequent decreasein physical activity point to the necessity of providingcomplete cardiovascular and physical rehabilitation.

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Fig. 1. Quad ricepsfemorismuscle setting. Fig. 2. Straight-leg-raisingexercise.

ACUTE INJURYDuring the acute injury period, the patient is insome type of immobilizer, cast, or supportive wrap.

The exercises of choice, whether the disorder is anextensor mechanism problem, a meniscal problem, ora ligamentous problem, is to start on a quadricepsfemoris setting program throughout the day (Fig. 1).Straight leg raises should be done three times a day.If tolerated by the patient, these exercises should bedone out ofthesupporting wrap (Fig. 2). The patientcan perform minimum terminal extensions along withthe straight leg raises (Figs. 3, 4). This will encouragefull extension and will squeeze the knee effusion,helping to speed its absorption. Resistance should bevery low (less than5lb or 2.3 kg) so as not to inflamethe damaged structure further. If the patient hasdifficulty contracting the quadriceps femoris muscle,he may perform a minimum terminal extension exercise to encourage contraction. The therapist mustmake certain that the patient does not substitute withthe gluteus medius, gluteus maximus, or hamstringmuscles when trying to do the quadriceps femorisexercise. This quadriceps femoris program can becontinued until further evaluation by the physicianand initiation of a progressive program. The usualmodalities for pain and swelling may also be used.The following progressive programs started duringthe acute injury period are for conservative (nonsurgical) treatment or for preoperative treatment forvarious disorders.Extensor Mechanism Injuries

The extensor mechanism injuries dictate that carebe taken to avoid irritating the structures involved.Exercises that involve flexion-to-extension motions orheavy resistance may aggravate these types of injuries.Such problems as subluxing patella, inflamed plica,patellofemoral crepitation, Osgood-Schlatter's disease, and any type of degenerative joint disease

should be treated with quadriceps femoris settingexercises, straight-leg-raising exercises, and hamstringstretching. The hamstring stretching is useful in preventing overcompression of the patella against theunderlying bony surface.Resistance for straight-leg-raising exercises is keptto an upper limit of 15 lb (6.8 kg). Most patientsshould be able to reach1 lb (4.5 kg). These patientsshould be given several months to work on thisprogram. In certain instances, bicycle riding can beencouraged if the activity does not create swelling ordiscomfort. The seat on the bicycle should be raised

Fig. 3. Terminalextension exercise througha short arcof m otion.

Fig. 4. Terminal extension exercise combined withstraight-leg-raiseexercise.Volume 60 / Number 12 December 1980 1603


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high enough so that the knee comes to full extensionat the bottom ofthepedal stroke. This will minimizeirritation of the patellofemoral joint. If the bike is thestationary type, the resistance should be kept low andthe patient should ride at a steady pace of about 12.5mph (20 kph). On an outdoor bicycle, the gears ofthe bicycle should be adjusted so that a steady pacemay be maintained. The patient should begin withabout 15 minutes of riding and increase to one hour.Running is often discouraged for those patients withthese types of knee problems because the biomechan-ical forces of running put great stress upon the extensor mechanism.

Meniscal InjuriesPatients with meniscal injuries do flexion-to-exten-sion exercises to strengthen the quadriceps femorismechanism (Fig. 5). If full-arc exercises cause pain,short-arc (terminal extension) or straight-leg-raise exercises should be substituted. Hamstring stretching,quadriceps femoris setting, and bicycling should beincluded in the program. If the initial evaluationreveals weaknesses in the hip muscles or other areas,appropriate rehabilitation exercises should be initiated (Figs. 6-10). Often individuals with horizontalcleavage tears of their menisci remain asymptomatic.Vertical tears of the menisci do notheal,but increasedstrength and flexibility around the knee may allowthe athlete to continue participating in sports untilthe appropriate surgical procedure is performed. Inthe nonathletic individual, increases in strength and

flexibility may allow the individual to avoid surgery.Ligamentous Injuries

Chronic ligamentous injuries will respond to quadriceps femoris setting, straight leg raises, and hamstring stretching. Depending on the condition of the

Fig. 5. Kneeextensionex-ercise as described in thetechniques of exercise.

Fig. 6. Hamstring exercise as described inthe techniques ofexer-cise.

Fig. 7. Hipflexion strengthening asdescribed inthe techniques of exercise.

Fig. 8. Hip Abduction strengtheningas describedin thetechniquesof exercise.

Fig. 9. Hip extension strengtheningas describedin thetechniques ofex-ercise.

Fig. 10. Hip adductionstrengthening as describedinthe techniques of exercise.

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joint,flexion to extensionexercises can be instituted.If there is a combined anterom edial and anterolateralinstability, full-arc exercise may tend to cause subluxation ofthetibia anteriorly an d increase the instability. Posterolateral instabilities should be exercised inan arc lacking 10 degrees of full extension, becausefull extension allows the tibia to rotate externallyagainst the pos terolateral part of the capsule. Patientswho have had chronic ligamentous instability forseveral years will show weaknesses in the hamstringand hip musculature. Bicycling is also indicated forthese problems.Many common problems, such as tendinitis, bursitis,and contusions, are seen by clinicians during theacute injury period. These conditions are often of theinflammation typ e and respond to rest, antiinflammatory agents, and supervised exercise. Supervisionis necessary to ensure that inflammation is controlledand not exacerbated.POSTOPERATIVE PERIOD

The postoperative period treatment regimen for thevarious types of surgical repairs depends on the patient. With a proximal or distal extensor reconstruction or a plica excision, the rehabilitation programbegins the day of surgery. The patient is encouragedto do ankle circumduction to promote circulatorybenefits in the lower extremity and to prevent phlebitis. The next day, quadriceps femoris setting isbegun (5 to 10 repetitions per hour), along with theankle-circumduction program. The patient may beginwalking and weight bearing to tolerance withcrutches. This program is done according to patienttolerance. It may be necessary to delay another dayif the patient feels quite uncomfortable after surgery.

Inasmuch as the extensor mechanism is involved,straight-leg-raise exercises are progressed slowly. Thepatient should be doing two to three sets of 5 legraises by the time of discharge (about seven days).The patient should be advised to increase repetitionsgradually until performing about eight sets of 10 legraises daily over the next three weeks. The exercise isincreased according to the patient's tolerance. Resistance is seldom added to this exercise. Hamstringstretching is also added during this period.Active and active-assistive flexion programs arebegun one week after plica excision and three weeksafter extensor mechanism surgeries. Active flexion isbegun by having the pa tient sit and attempt to flexthe knee, pushing the heel into the therapist's hand.This activates the hamstrings and inhibits the quadriceps femoris muscles, thus allowing an increase inthe flexion. These exercises may be painful and it isbest to begin gently. The first few treatments should

be active before adding the assistive routines. Judicious use of patellar mobilization techniques m ay behelpful in increasing range of motion. The patientcanuseany type of assistance forflexion.One methodis to have the patient sit and slide the foot as far aspossible, then plant the foot into thefloorashe movesforward over the planted foot. Patients may also usea rocking chair in much the same fashion, rockingforward over the stabilized foot. An under-the-tablerope and pulley may also be used to stimulate thehamstring muscles. An elastic wrap tied to the footand strapped to the back rung of the chair providesthe pa tient a means of independently assisting himselfat home. The patient is normally allowed six weeksfrom surgery to reach 90 degrees offlexion.If he doesnot attain this goal, many surgeons will performmanipulation under anesthesia. A knee-flexion program (as outlined above) is begun immediately afterthe manipulation to maintain the increased range.Patients who have meniscectomies are started onmuch the same program, but they are allowed tobegin straight-leg-raise exercises at day one and progress to about eight sets of 10 repetitions in a veryshort period of time. Progressive resistance can beadded at this point. Hamstring stretching exercisesand flexion exercises are begun about 10 days aftersurgery. An active-assistive program of flexion isused. Flexion-to-extension exercises are included intreatment programs for patients with meniscectomies.They are used when there is a full range of motionwith very little swelling or discomfort in or about theknee. Resistance is kept low but is raised as thepatient becomes able to handle the resistance withgood exercise technique. Bicycle riding is begun oncethere is full range of motion and no swelling.Individuals with arthroscopic meniscectomies arestarted on a much more vigorous exercise programmuch earlier. Flexion to extension is started within aday or two of the surgery and bicycling within theweek.Knees with ligamentous repair are immobilized forat least six weeks. The patient begins quadricepsfemoris setting and ankle range of motion at day one.Gait is nonweight bearing with crutches. Dependingon the extent of surgery, the quadriceps femoris setting exercises are usually much easier to perform ina flexion cast than out ofthecast because the patientcan use the cast to resist the contraction. The verycomplicated combined anteromedial, anterolateral,and posterolateral surgeries require an especially slowprogression. The patient begins straight-leg-raise exercises but may only be doing two to three sets of 5straight leg raises upon discharge (10 days after surgery) and will go home to progress to about eight setsof 10 straight leg raises daily. The patient uses no

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Fig. 11. Quad riceps fe-moris stretching as described in the techniques of exercise.

Right)Fig.12. Adductor stretching as described in the techniques of exercise.

Fig. 13. Abductor stretching as describedinth etechniquesof exercise. Fig. 14. Hip flexor stretchingas describedinth etechniquesof exercise. Fig. 15. Hamstring stretching exercises as describedin the techniquesof exercise.

resistance doing these exercises. We have found thattoo much quadriceps femoris muscle activity cancause the tibia to become subluxed anteriorly andstretch the repairedtissues.Three weeks after surgery,hip exercises in the cast can be added to ensure thatthe entire lower extremity is involved in the maintenance program.Some surgeons apply a hinge cast, which allowscontrolled range of motion. This cast is applied abou t10 days after surgery and allows protected motion.The patient is taught the appropriate exercises asdictated by the surgical procedure. These patientsprogress much more rapidly after the cast is removedand must be carefully monitored at that time. Aftersix to eight weeks of immobilization, the cast is removed and an active range-of-motion program isbegun. Exercises include an attempted straight legraise with minimum terminal extension and activeflexion. For anteromedial instabilities, knee extensionexercises can be added. For posterolateral repairs,flexion to extension, terminal extension, and straightleg raises are used. At two weeks after mobilization,an under-the-table rope and pulleyisused for gainingknee flexion and strengthening, along with the chairroutines as described earlier. As the necessary rangeof motion is obtained, standing hamstring exercisesare performed (Fig. 6). The resistance is kept verylow for the quadriceps femoris muscle exercisesnomore than 5 lb (2.3 kg) for the first month. It is veryimportant that the knee come into extensions ow yand under active quadriceps femoris mechanismpower. No passive extension should be done, because

it stretches the surgical reconstruction. Active-assis-tive flexion is used to gain knee flexion. The patientremains nonweight bearing with crutches for the nextthree to four weeks, until touch-down and partialweight bearing can be begun. The gait training shouldinclude tightening ofthequadriceps mechanism during weight bearing.INTERMEDIATE POSTOPERATIVE PERIOD

As patients with extensor mechanism problemsobtain their full range of motion after surgery, theyprogress in their straight-leg-raise exercise programtoward 10 to 15 lb (4.5-6.8 kg). Bicycle riding isbegun as soon as range of motion is full and inflammation is at a minimum . If flexion-to-extension activities are attempted with these patients, the knee willswell and progress will be slow. It may take longer torehabilitate extensor mechanism problems than otherdisorders.Patients with meniscectomies can progress withtheir programs rather quickly and begin bicyclingwithin the month and progress to 12.5 miles (20 km)a day. Running activities can be begun at this point.Sprintingisthe activity of choice because it minimizesthe repetitive compressive trauma upon the kneejoint. Stair running is an excellent activity to increasethe strength of the quadriceps femoris mechanism. Itis important to remember that ligamentous reorganization is an extensive process occurring much lessrapidly than muscular strengthening. Therefore, individuals undergoing ligamentous repairs or recon-

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structions should not be allowed to resume competitive athletics before adequate rehabilitation of thelower extremity and adequate maturation of the repaired or reconstructed ligamentous tissues.4, 5Generally, an athlete returning to competition followingligamentous repair must wait a year or longer to allowreorganization and maturation of the substitutedstructure. Patients who have ligamentous repairs mustwork on their hip exercises (Figs. 9, 10), quadricepsfemoris muscle strengthening, bicycling, and stairclimbing. The use of the step up is an importantfunctional activity for rehabilitation. Patients whohave undergone ligamentous repairs may require sixmonths to regain full extension but normally regainedfull flexion much earlier.Isokinetic exercise may be used in either a completeor limited arc. Patients with extensor mechanismproblems m ust work at high speeds of contraction (20

rpm or higher). If flexion-to-extension exercise of theknee causes any irritation, the exercise should bediscontinued. Patients with combined rotatory instabilities should do limited-arc exercises and must workat slow speeds at first to avoid damaging the reconstruction. Once the reconstruction firms up , theyshould increase their speed and range of motion. Acommonly used protocol consists of 30-sec bouts ofexercise with 30-seconds of rest between each bout.These bouts of exercise are performed at 5-rpm increments from 10 rpm to 50 rpm. M otivated patientsmay work at longer bouts at higher speeds as tolerated.ADVANCED POSTOPERATIVE PERIOD

Advanced rehabilitation for the patient who willreturn to athletics stresses the functional and specificaspects demanded by the sport. Those who have hadextensor mechanism repair and plica excisions mustcontinue with straight leg raises and bicycling. If therehas been any type of shaving of the patellofemoralsurfaces, it will take at least six months for the kneesurfaces to regenerate. To start flexion-to-extensionexercises before then will only invite further traumato theknee.Thus running and agility drills begin onlyafter sufficient strength has been attained and tissuerepair has occurred. When patients who have had ameniscectomy or ligamentous repair reach a 75 percent level of normal on their Cybex* isokineticdynamometer evaluation of the quadriceps femorismuscle and are riding the bicycle 12.5 miles (20 km)a day, advanced activities are begun with physicianapproval.

The following is an example of a progressive running program. Before starting to run , the patient mustbe able to walk two miles (3.2 km) without a limpand without having an increase in swelling. He thenalternates 100 yd (91.4 m) of walking with 100 yd(91.4 m) of jogging until he completes a quarter of amile during the first bout of exercise. The patientprogresses according to tolerance until he can jog aquarter of a mile in a straight line without problems.The distances are gradually increased to one mile.During this time the patient should be running w ithout a limp and without increased swelling. Once themile can be run fairly easily, the individual can begin40-yd dashes, first at half-speed and then progressingto fullspeed.Once these canbeperformed, the patientcan begin running and cutting. Also, agility activitiesmust be incorporated to enhance functional performance. The West Point Program demonstrates thisvividly.

6 But the many patients who cannot toleratethejogging in this program should begin sprint-typesof activity at half-speed. This seems to be easier onthe knee joint than is the continuous pounding ofjogging. Stair climbing can be included in this workout. Other functional activities may include figure-eight patterns, line backer and defensive back drills,and Z running.

The isokinetic dynamometerisused to measure thestrength of both lower extremities for a right-to-leftcomparison. Our experience with different types ofpatients shows that the quadriceps femoris mechanism takes much longer to rehabilitate than does thehip and hamstring musculature.An often-neglected component of performance isbalance. Ligamentous sprains involve the disruptionof capsular nerve endings.7 The inclusion of balanceactivities such as one-leg standing, weight shifting,and tilt board exercises is necessary if an individualis to attain his preinjury level of fitness.Rehabilitation is not complete until each muscle ofthe lower extremity is equal to or greater than theopposite side in strength and flexibility (Figs. 11-15).All functional activities should be done w ith the sameease and confidence that the patient possessed priorto surgery. The status of the patient's cardiovascularsystem must be superb if he is to participate inendurance activities. All running times should beequal to those performed before surgery. These criteria must be met before an individual can safelyreturn to competitive athletics.KNEE APPLIANCES

Many patients treated in physical therapy for kneeproblems can benefit from a supportive knee appliance. This portion of the paper gives a basic intro- Lumex, Inc, 100 Spence St, Bay Shore, NY 11706.Volume 60 / Number 12 December 1980 1 6 0 7


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Fig. 16. Palumbo PatellarStabilzation Brace used to prevent thelateral dislocationof thepa tella.Fig. 17. The Pro Dr. M.Brace used toalleviatediscomfortofpatellartendini-tis.

Fig. 18. The Lenox HillDerotation Brace to compensate forknee hype rex-tension varus/valgus orrotational instabilities.

duction to the selection and fabrication of these devices and should not be considered as a completeguide to the topic.The purposes of knee appliances are as follows: 1)to protect the surgical procedure during healing oftissues, 2) to compensate for decreased internal stabilization with an increased external stabilization system, and 3) to change the biomechanics of the knee(such as to pull a patella alta inferiorly or to increasethe space between the patella and the femur).The medical and lay communities have many misconceptions about knee appliances, for example, that1) a knee appliance will replace a thorough rehabilitation program, 2) a knee appliance will replace aconscientiously pursued strength/power maintenanceprogram, and 3) a knee appliance is always neededafter an injury.Appliance selection should be based on the following considerations: 1) there must be a definite need,2) the appliance must no t be used in a way that mightinjure the patient, 3) the particular device chosenmust m eet the established need, 4) the appliance mustlook reasonably attractive and feel comfortable to thepatient, and 5) the cost must be affordable.The various types of appliances can be categorizedby method of fabrication. Clinic fabrication includesuse of such appliances as a modified Levine strapand a felt lateral-patellar stabilizer and use of tape.Commercially fabricated devices include stockmodels such as a Levine strap, Pro-devices, dynamicpatellar stabilization braces, and cartilage braces.Commercially fabricated custom orthoses includethose designed to prevent the lateral dislocation of

the patella, such as the Palumbo Patellar StabilizationBrace (Fig.16),as wellasthose designed to alleviatethe discomfort of patellar tendinitis such as the ProDr. M. Brace** (Fig. 17).The reasons for using these appliances are the needfor additional support for the knee joint and theattempt to save money over the cost of custom-fabricated devices.Custom-made orthoses have been available for thepast several years and, although expensive, provide

maximum protection for the patient's knee. Theseorthoses, which include the Lenox Hill DerotationBrace (Fig. 18) and the Iowa Brace, will lastindefinitely if properly fitted and cared for. TheLenox Hill Derotation Brace requires the clinician tomark anatomical landmarks with a water-soluble penon a stockinette that the patient is wearing. Thepatient is then casted, with the markings ultimatelybeing transferred to the wet plaster. W hen the plastercast (negative mold) is filled with plaster, the markings are transferred for a second time onto the positivemold. The orthotist then fabricates the b race over thepositive mold to accommodate both for knee size andtype of instability. For example, a Lenox Hill Bracemay be fabricated to compensate for knee hyperex-tension, varus/valgus, or ro tational instabilities.

Our treatment programs are based on what hasbeen successful for our patients in our clinics. Ourtreatment decisions have been based on empirical

Jack Levine, MD , Director, Department of Orthopaedic Surgery, Brookdale Hospital M edical Center, Linden Blvd at BrookdalePlaza, Brooklyn, NY 11212.

P.M. Palum bo, M D, 8206 Leesburg Pike, McLean, VA 22180.* * Pro O rthoped ic D evices, Inc, PO Box 1, King of Prussia, PA19406. Lenox Hill Brace S hop, Inc, 100 E 77 St, New Yo rk, N Y10021.

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data, rather than on controlled laboratory study. Clinical research must now be done to verify our theoriesand procedures .

This bas ic in format ion regarding knee appl iancesand the type of problems they may a l lev iate i s toserve only as an introduction. We hope that it wills t imulate the physical therapy c l in ic ian to becomemore in terested in evaluat ing pat ients who mightbenefit from these devices and consult with theirphysic ians regarding the ir poss ib le use .

SUMMARYKnee rehabilitat ion is nearly as complex as the

k n e e itself The general and specif ic programs andexercises presented are to be used eclect ically. Rehabilitat ion must not be of a cookbook nature but ratherindividualized to f it the needs of the patient . Theemphasis of rehabilitat ion must be dictated by thedemands the ind iv idual p laces upon the knee . Rehabilitat ion must degenerate into function

APPENDIXTechniques of Exercise

The following exercises represent o ur routine techniquesthat are adapted according to each patient s response. Thecritical factor in each exercise program is for the therapist toavoid causing the patient swelling or discomfort while ha vinghim work to his maximum exercise tolerance.

Quadriceps Femoris Setting Exercise:Quadriceps femoris setting is an isometric contraction ofthe quadriceps femoris mechanism, usually with the kneein full extension. The patient contracts the quadricepsfemoris muscle, causing the patella to track proximallyand the leg to be straightened as much as possible.Because this is an isometric exercise, the contractionshould be held for a full six-second count. The patientperforms 50 of these exercises an hour during everywaking hour (Fig. 1).Straight-Leg-Raising Exercise:The patient is positioned supine, perhaps on his elbows,with the uninvolved leg flexed to 90 degrees and footplanted flat next to the involved knee. He contracts theinvolved quadriceps femoris muscle and then lifts the legup to 45 degrees. He holds the leg there for a count oftwo and then lowers it to the floor and relaxes it for acount of two. The knee should be at full extensionthroughout the lift. The quadriceps femoris muscle mustbe contracted and the knee held in full extension beforethe leg is lifted. The patient does eight sets of 10 lifts witha 30-second to 1-minute rest between each set of 10.Straight leg raises are done three different times a day.Ankle weights provide progressive resistance. The patientbegins with a weight that he can lift easily, yet that makeshim tired after eight sets of 10 lifts. The k nee must rem ainin the same amount of extension on the last lift as it didon the first, as if there were no weight at the ankle at all.This is an easy way to estimate how much weight to useon these exercises. The weight is increased according tothe patient's tolerance (Fig. 2).Terminal Extension Exercise:If support is placed beneath the popliteal fossa duringstraight leg raises, a terminal knee extension exercise can

be added to the program. This short-arc quadriceps femoris exercise allows exercise through a range of motion.When the patient is having trouble gaining full kneeextension, he should do minimal terminal extension exercises. Here, the support beneath the knee sjust enoughso that when the patient contracts the quadriceps femorismuscle as tightly as possible, the heel w ill clear the exercisesurface by less than an inch. This encourages the patientto work harder on extending the knee and on using moremotor fibers of the quadriceps femoris muscle. Fifty ofthese exercises are done three different times a day. Resistance can be added as necessary. The terminal knee-extension exercise can be used with the straight-leg-raiseexercise. When the patient has the knee extended to itsfullest amount, he can raise the entire leg up to a 45-degree angle of the hip and continue the straight-leg-raisetechnique (Figs. 3, 4).

Knee Extension Exercise:This exercise is done from 90 degrees of flexion to thefullest amount of extension. The exercise should be donewith the foot resting on the floor or stool and is termed"bottomed out." (This means that if the patient sits withthe legs dangling and weights attached, the ligaments ofthe knee could be stretched through the pull of gravity.)The patient extends his knee, pauses for a count of two,and then flexes back to 90 degrees with the foot resting onthe floor. After a two-count rest, the exercise is repeated.Eight sets of 10 are allowed. Resistance is added in muchthe same way as with the straight leg raise (Fig. 5).

Hamstring Exercise:The patient stands with the anterior part of the thighpressed against a wall or table to block hip flexion. Heflexes the knee to its fullest position, holds it for twocounts, and low ers it to the floor. The individual does fourto eight sets o f 10 lifts three different times a day. Resistance is added and progressed according to the patient'stolerance (Fig. 6).Hip Flexion Exercise:The patient sits on a firm surface, feet resting on the floor.He flexes his hip toward his chest at about a 45-degreeangle. He holds it there for two counts and then lowers itfor a two-count rest. This exercise is done in four sets of10 repetitions three different times a day. The clinician

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can add resistance by placing a barbell plate weight onthe knee and holding it with the contralateral hand, whilethe ipsilateral hand grasps the front of the sitting surfaceto prevent the patient's leaning backward (Fig. 7).Hip Abduction Exercise:The patient lies, in relation to his affected knee, on hiscontralateral side with his contralateral knee flexed to 90

degrees for stability. He performs a quadriceps femorissetting exercise and then lifts the leg in the frontal planeof the body. F ou r sets of 10 repetitions are performedthree times a day w ith 30-second to1 minuterests betwe eneach set. Resistance can be added at the ankle. Theindividual must not flex his hip during this exercise orrotate his trunk posteriorly (Fig. 8).An alternate exercise program for the hip abductor muscles can be done isometrically. A belt is strapped justproximal to the knees and the patient abducts the thighagainst the belt, holding for a six-second count and thenrelaxing. This should be done 25 times, three differenttimes a day.

Hip Extension Exercise:The patient positions himself over a firm table or bed,with the edg e of the surface at the hip joint line. From theprone position he extends his hip on the involved sidewith the knee in full extension to the normal amount ofextension at the hip . He holds this position for two counts,lowers his leg, rests for two coun ts, and the n repeats. Fou rsets of 10 repetitions a re don e an d progressive resistanceadded as necessary (Fig. 9).

Hip Adduction Exercise:The easiest way to strengthen the hip adductor muscle isby an isometric exercise. The patient places a basketballor a soccer-type ball between his knees and then squeezesthe ball, holding for a six-second count. This is repeated25 times three different times a day. He may do thissupine, sitting, or standing (Fig. 10).Quadriceps Femoris Stretching:The patient lies prone and pulls his heel toward hisbuttock. He holds for 10 counts, then releases. Fiveminutes of stretching is preferred (Fig. 11).Adductor Stretching:The patient sits with soles of his feet together and slidesthem toward the buttocks. He actively pulls his kneestowa rd the floor an d holds for 10 counts, then releases.Five minutes of stretching is preferred (Fig. 12).Abductor Stretching:The patient lies on his side with his bottom leg flexedforward so that his top leg with knee flexed can touchfloor. H e holds this position for 10 counts and thenreleases. Five minutes of stretching is preferred (Fig. 13).Hip Flexor Stretch:The patient lies supine. He pulls one knee to his chest andextends the opposite leg as hard as possible. He holds for10 counts, then releases. Five minutes of stretching ispreferred (Fig. 14).Hamstring Stretch:The patient assumes a long-sitting position with one legoff the exercise surface. He slowly leans forwardnobounc ing is allowed. H e holds for 10 counts, then releases.Five minutes of stretching is preferred (Fig. 15).

REFERENCES1. D eL o rme T L: Re st o ra t io n o f m u scle p o w er b y h ea vy re s is t a n c e e x e r c i s e . J B o n e J o in t S ur g 2 7 : 6 4 5 - 6 6 7 1 9 4 52 . Z in o vie ff A N : H ea vy res is t a n ce e xerc ise : Th e O xfo rd t ech n iq u es . Br J P h ys M ed 14 :2 9-3 2 19513 . Kn ight KL: K ne e rehab il i tat ion by the daily adjustable progress ive res is t a n ce exerc ise t ech n iq u es . A m J S p o rt s M ed7 : 3 3 6 - 3 3 7 1 9 8 04 . No ye s FR Grood ES: Strength of the in terior cruciate l igam en t in h u m a n s a n d rh esu s: A ge a n d sp ec ies-re la t edch a n ge s . J B o n e Jo in t S u rg [Am ] 58:1 074 197 6

5. No ye s FR DeLuca s JL Torvic PJ: Biom ech an ics of anteriorcruciate l igament fa i lure: An an alysis of strain-rate sen sit ivityand mechanisms of fa i lure in primates. J Bone Joint Surg[Am ] 56:23 6 197 46. Yama moto SK Hartman CW Feagin JA et a l: Funct ionalrehab il i tat ion of the kne e: A prel iminary study. J Sports Med3 : 2 8 8 1 9 7 67. Freema n MAR Dean MR E Han ham IF: The et io lo gy andprevent ion of funct ional instabil i ty of the foot . J Bone JointS u rg [Br] 47 :6 78 -68 5 196 5

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1980; 60:1602-1610.PHYS THER.Terry Malone, Turner A Blackburn and Lynn A WallaceKnee Rehabilitation

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