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Squatting
Contents 2. The Strain Behavior of the Anterior Cruciate Ligament During Squatting and Active Flexion-Extension 3. A Comprehensive Rehabilitation Program With Quadriceps Strengthening in Closed Versus Open Kinetic Chain Exercise in Patients With Anterior Cruciate Ligament Deficiency 4. Role of the Vastus Medialis Obliquus in Repositioning the Patella

The Strain Behavior of the Anterior Cruciate Ligament During Squatting and Active Flexion-Extension
A Comparison of an Open and a Closed Kinetic Chain Exercise
1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. 1. Bruce D. Beynnon, PhD McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, Vermont Robert J. Johnson, MD McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, Vermont Braden C. Fleming, MS McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, Vermont Charles J. Stankewich, MS McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, Vermont Per A. Renstrm, MD, PhD McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, Vermont Claude E. Nichols, MD McClure Musculoskeletal Research Center, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, Vermont

Abstract
The effects of weightbearing (closed kinetic chain) and nonweightbearing (open kinetic chain) exercises on the biomechanical behavior of an injured anterior cru ciate ligament or a healing anterior cruciate ligament graft are unknown. To understand the effects of these exercises on the healing graft, we measured the strain behavior of the normal anterior cruciate ligament in human subjects while they performed squatting, a closed kinetic chain exercise, and active flexion-exten sion of the leg, an open kinetic chain exercise. The maximum anterior cruciate ligament strain values ob tained during squatting did not differ from those ob tained during active flexion-extension. Also, anterior cruciate ligament strain values obtained during squat ting were unaffected by the application of elastic resis tance intended to increase muscle activity. These find ings indicate that squatting, which produces a substantial compressive joint force, does not necessar ily protect the anterior cruciate ligament more than active flexionextension of the leg, which is character ized primarily by contraction of the dominant quadri ceps muscle. These findings also demonstrate that increasing resistance during the squat exercise does not produce a significant increase in anterior cruciate ligament strain values, unlike increased resistance dur ing active flexion-extension exercise.

A Comprehensive Rehabilitation Program With Quadriceps Strengthening in Closed Versus Open Kinetic Chain Exercise in Patients With Anterior Cruciate Ligament Deficiency
A Randomized Clinical Trial Evaluating Dynamic Tibial Translation and Muscle Function
1. 2. 3. 4. 1. Sofi Tagesson, RPT ,*, Birgitta berg, RPT, PhD , Lars Good, MD, PhD , and Joanna Kvist, RPT, PhD From the Division of Physiotherapy, Department of Medicine and Health Sciences, and the Division of Orthopaedics and Sports Medicine, Department of Clinical and Experimental Medicine, Linkpings Universitet, Linkping, Sweden Address correspondence to Sofi Tagesson, RPT, Department of Medicine and Health Sciences, Division of Physiotherapy, Linkpings Universitet, SE-581 83 Linkping, Sweden (e-mail: sofi.tagesson@ihs.liu.se)

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Abstract
Background: There is no consensus regarding the optimal rehabilitation regimen for increasing quadriceps strength after anterior cruciate ligament (ACL) injury. Hypothesis: A comprehensive rehabilitation program supplemented with quadriceps strengthening in open kinetic chain (OKC) exercise will increase quadriceps strength and improve knee function without increasing static or dynamic sagittal tibial translation, compared with the same comprehensive rehabilitation program supplemented with quadriceps strengthening in closed kinetic chain (CKC) exercise, in patients with acute ACL deficiency. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Forty-two patients were tested a mean of 43 days (range, 20 96 days) after an ACL injury. Patients were randomized to rehabilitation with CKC quadriceps strengthening (11 men and 9 women) or OKC quadriceps strengthening (13 men and 9 women). Aside from these quadriceps exercises, the 2 rehabilitation programs were identical. Patients were assessed after 4 months of rehabilitation. Sagittal static translation and dynamic tibial translation were evaluated with a CA-4000 electrogoniometer. Muscle strength, jump performance, and muscle activation were also assessed. Functional outcome was evaluated by determining the Lysholm score and the Knee Injury and Osteoarthritis Outcome Score. Results: There were no group differences in static or dynamic translation after rehabilitation. The OKC group had significantly greater isokinetic quadriceps strength after rehabilitation (P = .009). The hamstring strength, performance on the 1-repetition-maximum squat test, muscle activation, jump performance, and functional outcome did not differ between groups. Conclusions: Rehabilitation with OKC quadriceps exercise led to significantly greater quadriceps strength compared with rehabilitation with CKC quadriceps exercise. Hamstring strength, static and dynamic translation, and functional outcome were similar between groups. Patients with ACL deficiency may need OKC quadriceps strengthening to regain good muscle torque.

Role of the Vastus Medialis Obliquus in Repositioning the Patella

A Dynamic Computed Tomography Study
1. 2. 3. 4. 5. 6. 1. Yeong-Fwu Lin, PhD, MD*, , Jiu-Jenq Lin, PhD, PT , Mei-Hwa Jan, MS, PT , Tung-Ching Wei, MS, PT , Hsin-Yen Shih, PT , and Cheng-Kung Cheng, PhD*, From the *Graduate Institute of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan, Department of Orthopedic Surgery, West Garden Hospital, Taipei, Taiwan, and School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, and Department of Rehabilitation and Physical Medicine, National Taiwan University Hospital, Taipei, Taiwan Address correspondence to Cheng-Kung Cheng, PhD, Orthopedic Biomechanics Laboratory, Institute of Biomedical Engineering, National Yang-Ming University, No. 155, Sec. 2, Li-Nung St, Taipei 112, Taiwan (email: ckcheng@ym.edu.tw).

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Abstract
Background: It has been assumed that patellofemoral pain syndrome results from patellar malalignment. The precise role the vastus medialis obliquus plays in mediating the underlying pathologic abnormality is unclear. Hypothesis: The morphologic characteristics of the vastus medialis obliquus correlate to patellar malalignment in patients with patellofemoral pain syndrome. Study Design: Cross-sectional study; Level of evidence, 3. Methods: One hundred twelve patients with patellofemoral pain syndrome were studied. Six sets of computed tomography axial images were assessed in which knee flexion was 0, 15, or 30 and the quadriceps muscle either relaxed or contracted. Measurements of serial cross-sectional areas of the vastus medialis obliquus and patellar malalignment were made. Correlation and stepwise regression models between the vastus medialis obliquus variables and patellar malalignment (lateral shift and patellar tilt) were calculated. Statistics were calculated on 4 subgroups depending on patellofemoral malalignment type. Results: Significant correlations were found between measures of cross-sectional areas of vastus medialis obliquus and patellar tilt at 0 and 30 of knee flexion. Using a regression model, it was determined that vastus medialis obliquus is predictive of patellar tilt (R2 = 0.078 0.130). This explanation was most apparent in the subgroup of patients with extreme patellar tilt and lateral shift malalignments (R2 up to 0.824). Conclusion: There are significant correlations between vastus medialis obliquus variables and patellar malalignments in extended knees of patients with patellofemoral pain syndrome. Clinical Relevance: Vastus medialis obliquus muscle function is important to consider in the rehabilitation of patients with patellofemoral pain syndrome, especially those with extreme patellar tilt and lateral shift malalignments.