How do you safely & effectively implement Leg Press & Knee Extensions in the early phase after a combined ACL and meniscus reconstruction?

This is the 3. post, in the continuing series on BFR augmented rehab for ACL-R and sutured meniscus, currently 6 weeks post op.

In the video you will find that the exercise selection has been progressed by single leg press and end-range isotonic knee extension. Additionally, we’re utilizing contralateral high load resistance training for the inter-set rest periods.

The primary concern for the leg press is the compressive force within the knee, possibly affecting the sutured meniscus. Though, as the meniscus has a rich supply of pain receptors, monitoring any aggravation is most likely sufficient for monitorization of progression e.g., load and ROM.

In the 2. part of the video knee extension has been progressed from end range isometric contraction to limited-range isotonic contraction.

It is commonly described that Open-Kinetic-Chain (OKC) exercises like knee extension creates detrimental anterior forces within the knee.

For this reason many recommend to avoid OKC after ACL-R because of the proposed strain on the graft increasing knee laxity.

Though, when examining the vast amount of research, it seems less of importance beyond 4 weeks post op. On the other hand, it seems appropriate to limit ROM from 90-40° when using moderate or high relative load for OKC exercises at 4-12 weeks post ACL-R.

Secondly, considering the tensile force from the anterior glide of the shin bone relative to femur, it is recommended to place the shin pad more proximally. With the pad positioned mid-shin vs ankle level, the strain on the ACL is approximately 50% less.

But utilizing low-load we can probably exercise the joint in full ROM with less of a concern in regards to graft stress. And by augmenting this low-load condition by BFR we can amplify the muscular recruitment similarly to a high-load condition.

Apparently, BFR can be such a game changer especially for the early-mid phase rehab in ACL-R.

Any thoughts on this exercise prescription or concerns for laxity?

Primary Source:

Perriman et al. (2018) The Effect of Open- Versus Closed-Kinetic-Chain Exercises on Anterior Tibial Laxity, Strength, and Function Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.