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

The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/60/12/1602 Collections This article, along with others on similar topics, appears in the following collection(s): Injuries and Conditions: Knee Sports Physical Therapy Therapeutic Exercise

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of that surgery is dependent upon a disciplined exercise program. This principle applies to programs not only for the athlete but for the nonathlete. Knee musculature cannot be expected to approach normal strength without such a disciplined program. Many TERRY MALONE, MS, knee programs have the potential of helping the TURNER A. BLACKBURN, MEd, patient reach the goal of normal strength, but their and LYNN A. WALLACE, MS success depends on discipline. It takes perseverance to succeed. Key Words: Exercise Therapy, Knee, Our programs are designed to be done at home and Physical Therapy. to use equipment available to the patient, inasmuch as many of our patients live out-of-town. Also, our programs are designed to carry over from the home Although many knee rehabilitation programs exist, to the hospital and back to the home again. there are few laboratory-controlled studies comparing Before designing a knee program, we carefully the efficacy of these particular programs. Most pro- evaluate the knee as outlined in the article in this grams, therefore, are based on clinical experience and issue on evaluation. This evaluation provides a data empirical data. This article presents rehabilitation base for successfully designing and implementing an programs we have found from clinical experience to adequate rehabilitation program. A preliminary diwork with many types of knee disorders. In our clinics agnosis is made as soon as possible after an acute we treat several hundred patients with knee problems knee injury. This preliminary diagnosis assists theraeach year, inasmuch as our practices are primarily pists in designing and implementing the rehabilitation oriented toward orthopedic sports medicine. The knee program. The rehabilitation is begun as rapidly as disorders range from contusion to surgical reconstruc- possible. Surgery, should it be performed, is done tion. early because after 10 days the torn ligamentous Our programs are presented here in order of the structures become very difficult to repair. Swelling in various periods of rehabilitation. We have tried to the knee joint may not allow the surgeon to make a emphasize general rehabilitation rather than specific definitive diagnosis immediately so that he can do the strength training because this article is directed to the surgery if necessary. Exercises can be used to decrease physical therapy practitioner rather than the athletic the effusion or hemarthrosis in the knee and thus trainer. This article also describes the use of appli- allow the knee to be examined more effectively. Ofances often integrated into a comprehensive rehabil- ten, exercises will decrease the swelling enough so itation program. that the knee joint will not have to be aspirated. GENERAL GUIDELINES Our rehabilitation programs, designed to deal with pathological conditions, are based on high repetition and relatively low resistance. Following this principle minimizes the stress placed upon the knee. In a healthy knee, a low-repetition, high-resistance program has its benefits, but in many knee disorders the supporting structures or articular surfaces often cannot safely handle the high resistance. Swelling and discomfort commonly result. The DeLorme1 and Oxford2 techniques are excellent for building strength in normal knees. Dr. Ken Knight's DAPRE also appears to build strength quickly.3 But in our hands, these programs have irritated many of the knee problems. We believe that the critical factor in the success of an exercise program is to avoid causing swelling and discomfort while having the patient work to his maximum exercise tolerance. Our knee rehabilitation programs are also based on the belief that if knee surgery is performed, the success 1602 Chronic knee instabilities often require reconstruction. These procedures are normally more difficult and complex than acute injury repairs. The chronically involved knee will benefit from an exercise program to the extent that the problem may be diminished through increased strength or flexibility. Even if the problem is not negated, at least the extremity will be better able to withstand surgery. The exercise programs vary depending on the problem and the condition of the patient. After surgery for acute or chronic problems, a vigorous rehabilitation program must be undertaken with the goal of rebuilding the strength of the involved extremity as well as the entire body. The extremity must regain range of motion and function. The true test of rehabilitation is whether the patient can return to the same level of function he had before the injury. The debilitation of the body during and after major knee surgery and the subsequent decrease in physical activity point to the necessity of providing complete cardiovascular and physical rehabilitation. PHYSICAL THERAPY
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Knee Rehabilitation

Fig. 1. Quadriceps femoris muscle setting.

Fig. 2. Straight-leg-raising exercise.

ACUTE INJURY

During the acute injury period, the patient is in some type of immobilizer, cast, or supportive wrap. The exercises of choice, whether the disorder is an extensor mechanism problem, a meniscal problem, or a ligamentous problem, is to start on a quadriceps femoris 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 be done out of the supporting wrap (Fig. 2). The patient can perform minimum terminal extensions along with the straight leg raises (Figs. 3, 4). This will encourage full extension and will "squeeze" the knee effusion, helping to speed its absorption. Resistance should be very low (less than 5 lb or 2.3 kg) so as not to inflame the damaged structure further. If the patient has difficulty contracting the quadriceps femoris muscle, he may perform a minimum terminal extension exercise to encourage contraction. The therapist must make certain that the patient does not substitute with the gluteus medius, gluteus maximus, or hamstring muscles when trying to do the quadriceps femoris exercise. This quadriceps femoris program can be continued until further evaluation by the physician and initiation of a progressive program. The usual modalities for pain and swelling may also be used. The following progressive programs started during the acute injury period are for conservative (nonsurgical) treatment or for preoperative treatment for various disorders. Extensor Mechanism Injuries The extensor mechanism injuries dictate that care be taken to avoid irritating the structures involved. Exercises that involve flexion-to-extension motions or heavy 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
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should be treated with quadriceps femoris setting exercises, straight-leg-raising exercises, and hamstring stretching. The hamstring stretching is useful in preventing overcompression of the patella against the underlying bony surface. Resistance for straight-leg-raising exercises is kept to an upper limit of 15 lb (6.8 kg). Most patients should be able to reach 10 lb (4.5 kg). These patients should be given several months to work on this program. In certain instances, bicycle riding can be encouraged if the activity does not create swelling or discomfort. The seat on the bicycle should be raised

Fig. 3. Terminal extension exercise through a short arc of motion.

Fig. 4. Terminal extension exercise combined with straight-leg-raise exercise.

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high enough so that the knee comes to full extension at the bottom of the pedal stroke. This will minimize irritation of the patellofemoral joint. If the bike is the stationary type, the resistance should be kept low and the patient should ride at a steady pace of about 12.5 mph (20 kph). On an outdoor bicycle, the gears of the bicycle should be adjusted so that a steady pace may be maintained. The patient should begin with about 15 minutes of riding and increase to one hour. Running is often discouraged for those patients with these types of knee problems because the biomechanical forces of running put great stress upon the extensor mechanism.

Meniscal Injuries Patients with meniscal injuries do flexion-to-extension exercises to strengthen the quadriceps femoris mechanism (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 be included in the program. If the initial evaluation reveals weaknesses in the hip muscles or other areas, appropriate rehabilitation exercises should be initiated (Figs. 6-10). Often individuals with horizontal cleavage tears of their menisci remain asymptomatic. Vertical tears of the menisci do not heal, but increased strength and flexibility around the knee may allow the athlete to continue participating in sports until the appropriate surgical procedure is performed. In the 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. Knee extension exercise as described in the techniques of exercise.

Fig. 6. Hamstring exercise as described in the techniques of exercise.

Fig. 8. Hip Abduction strengthening as described in the techniques of exercise.

Fig. 10. Hip adduction strengthening as described in the techniques of exercise. Fig. 7. Hip flexion strengthening as described in the techniques of exercise. Fig. 9. Hip extension strengthening as described in the techniques of exercise. PHYSICAL THERAPY

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joint,flexion-to-extensionexercises can be instituted. If there is a combined anteromedial and anterolateral instability, full-arc exercise may tend to cause subluxation of the tibia anteriorly and increase the instability. Posterolateral instabilities should be exercised in an arc lacking 10 degrees of full extension, because full extension allows the tibia to rotate externally against the posterolateral part of the capsule. Patients who have had chronic ligamentous instability for several years will show weaknesses in the hamstring and hip musculature. Bicycling is also indicated for these problems. Many common problems, such as tendinitis, bursitis, and contusions, are seen by clinicians during the acute injury period. These conditions are often of the "inflammation type" and respond to rest, antiinflammatory agents, and supervised exercise. Supervision is necessary to ensure that inflammation is controlled and not exacerbated.

be active before adding the assistive routines. Judicious use of patellar mobilization techniques may be helpful in increasing range of motion. The patient can use any type of assistance forflexion.One method is to have the patient sit and slide the foot as far as possible, then plant the foot into theflooras he moves forward over the planted foot. Patients may also use a rocking chair in much the same fashion, rocking forward over the stabilized foot. An under-the-table rope and pulley may also be used to stimulate the hamstring muscles. An elastic wrap tied to the foot and strapped to the back rung of the chair provides the patient a means of independently assisting himself at home. The patient is normally allowed six weeks from surgery to reach 90 degrees offlexion.If he does not attain this goal, many surgeons will perform manipulation under anesthesia. A knee-flexion program (as outlined above) is begun immediately after the manipulation to maintain the increased range. Patients who have meniscectomies are started on POSTOPERATIVE PERIOD much the same program, but they are allowed to begin straight-leg-raise exercises at day one and progThe postoperative period treatment regimen for the ress to about eight sets of 10 repetitions in a very various types of surgical repairs depends on the pa- short period of time. Progressive resistance can be tient. With a proximal or distal extensor reconstruc- added at this point. Hamstring stretching exercises tion or a plica excision, the rehabilitation program and flexion exercises are begun about 10 days after begins the day of surgery. The patient is encouraged surgery. An active-assistive program of flexion is to do ankle circumduction to promote circulatory used. Flexion-to-extension exercises are included in benefits in the lower extremity and to prevent phle- treatment programs for patients with meniscectomies. bitis. The next day, quadriceps femoris setting is They are used when there is a full range of motion begun (5 to 10 repetitions per hour), along with the with very little swelling or discomfort in or about the ankle-circumduction program. The patient may begin knee. Resistance is kept low but is raised as the walking and weight bearing to tolerance with patient becomes able to handle the resistance with crutches. This program is done according to patient good exercise technique. Bicycle riding is begun once tolerance. It may be necessary to delay another day there is full range of motion and no swelling. if the patient feels quite uncomfortable after surgery. Individuals with arthroscopic meniscectomies are Inasmuch as the extensor mechanism is involved, started on a much more vigorous exercise program straight-leg-raise exercises are progressed slowly. The much earlier. Flexion to extension is started within a patient should be doing two to three sets of 5 leg day or two of the surgery and bicycling within the raises by the time of discharge (about seven days). week. The patient should be advised to increase repetitions Knees with ligamentous repair are immobilized for gradually until performing about eight sets of 10 leg at least six weeks. The patient begins quadriceps raises daily over the next three weeks. The exercise is femoris setting and ankle range of motion at day one. increased according to the patient's tolerance. Resist- Gait is nonweight bearing with crutches. Depending ance is seldom added to this exercise. Hamstring on the extent of surgery, the quadriceps femoris setstretching is also added during this period. ting exercises are usually much easier to perform in Active and active-assistive flexion programs are a flexion cast than out of the cast because the patient begun one week after plica excision and three weeks can use the cast to resist the contraction. The very after extensor mechanism surgeries. Active flexion is complicated combined anteromedial, anterolateral, begun by having the patient sit and attempt to flex and posterolateral surgeries require an especially slow the knee, pushing the heel into the therapist's hand. progression. The patient begins straight-leg-raise exThis activates the hamstrings and inhibits the quad- ercises but may only be doing two to three sets of 5 riceps femoris muscles, thus allowing an increase in straight leg raises upon discharge (10 days after surthe flexion. These exercises may be painful and it is gery) and will go home to progress to about eight sets best to begin gently. The first few treatments should of 10 straight leg raises daily. The patient uses no Volume 60 / Number 12, December 1980

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Fig. 11. Quadriceps femoris 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 described in the techniques of exercise.

Fig. 14. Hip flexor stretching as de- Fig. 15. Hamstring stretching exerscribed in the techniques of exercise. cises as described in the techniques of exercise.

resistance doing these exercises. We have found that too much quadriceps femoris muscle activity can cause the tibia to become subluxed anteriorly and stretch the repaired tissues. Three weeks after surgery, hip exercises in the cast can be added to ensure that the entire lower extremity is involved in the maintenance program. Some surgeons apply a hinge cast, which allows controlled range of motion. This cast is applied about 10 days after surgery and allows "protected" motion. The patient is taught the appropriate exercises as dictated by the surgical procedure. These patients progress much more rapidly after the cast is removed and must be carefully monitored at that time. After six to eight weeks of immobilization, the cast is removed and an active range-of-motion program is begun. Exercises include an attempted straight leg raise with minimum terminal extension and active flexion. For anteromedial instabilities, knee extension exercises can be added. For posterolateral repairs, flexion to extension, terminal extension, and straight leg raises are used. At two weeks after mobilization, an under-the-table rope and pulley is used for gaining knee flexion and strengthening, along with the chair routines as described earlier. As the necessary range of motion is obtained, standing hamstring exercises are performed (Fig. 6). The resistance is kept very low for the quadriceps femoris muscle exercisesno more than 5 lb (2.3 kg) for the first month. It is very important that the knee come into extension slowly and under active quadriceps femoris mechanism power. No passive extension should be done, because 1606

it stretches the surgical reconstruction. Active-assistive flexion is used to gain knee flexion. The patient remains nonweight bearing with crutches for the next three to four weeks, until touch-down and partial weight bearing can be begun. The gait training should include tightening of the quadriceps mechanism during weight bearing.
INTERMEDIATE POSTOPERATIVE PERIOD

As patients with extensor mechanism problems obtain their full range of motion after surgery, they progress in their straight-leg-raise exercise program toward 10 to 15 lb (4.5-6.8 kg). Bicycle riding is begun 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 will swell and progress will be slow. It may take longer to rehabilitate extensor mechanism problems than other disorders. Patients with meniscectomies can progress with their programs rather quickly and begin bicycling within the month and progress to 12.5 miles (20 km) a day. Running activities can be begun at this point. Sprinting is the activity of choice because it minimizes the repetitive compressive trauma upon the knee joint. Stair running is an excellent activity to increase the strength of the quadriceps femoris mechanism. It is important to remember that ligamentous reorganization is an extensive process occurring much less rapidly than muscular strengthening. Therefore, individuals undergoing ligamentous repairs or reconPHYSICAL THERAPY

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structions should not be allowed to resume competiThe following is an example of a progressive runtive athletics before adequate rehabilitation of the ning program. Before starting to run, the patient must lower extremity and adequate maturation of the re- be able to walk two miles (3.2 km) without a limp paired or reconstructed ligamentous tissues.4, 5 Gen- and without having an increase in swelling. He then erally, an athlete returning to competition following alternates 100 yd (91.4 m) of walking with 100 yd ligamentous repair must wait a year or longer to allow (91.4 m) of jogging until he completes a quarter of a reorganization and maturation of the substituted mile during the first bout of exercise. The patient structure. Patients who have ligamentous repairs must progresses according to tolerance until he can jog a work on their hip exercises (Figs. 9, 10), quadriceps quarter of a mile in a straight line without problems. femoris muscle strengthening, bicycling, and stair The distances are gradually increased to one mile. climbing. The use of the "step up" is an important During this time the patient should be running withfunctional activity for rehabilitation. Patients who out a limp and without increased swelling. Once the have undergone ligamentous repairs may require six mile can be run fairly easily, the individual can begin months to regain full extension but normally regained 40-yd dashes, first at half-speed and then progressing full flexion much earlier. to full speed. Once these can be performed, the patient Isokinetic exercise may be used in either a complete can begin running and cutting. Also, agility activities or limited arc. Patients with extensor mechanism must be incorporated to enhance functional performWest Point Program demonstrates this problems must work at high speeds of contraction (20 ance. The 6 rpm or higher). If flexion-to-extension exercise of the vividly. But the many patients who cannot tolerate knee causes any irritation, the exercise should be the jogging in this program should begin sprint-types discontinued. Patients with combined rotatory insta- of activity at half-speed. This seems to be easier on bilities should do limited-arc exercises and must work the knee joint than is the continuous pounding of at slow speeds at first to avoid damaging the recon- jogging. Stair climbing can be included in this work struction. Once the reconstruction "firms up," they out. Other functional activities may include figureshould increase their speed and range of motion. A eight patterns, line backer and defensive back drills, commonly used protocol consists of 30-sec bouts of and Z running. exercise with 30-seconds of rest between each bout. The isokinetic dynamometer is used to measure the These bouts of exercise are performed at 5-rpm incre- strength of both lower extremities for a right-to-left ments from 10 rpm to 50 rpm. Motivated patients comparison. Our experience with different types of may work at longer bouts at higher speeds as toler- patients shows that the quadriceps femoris mechaated. nism takes much longer to rehabilitate than does the hip and hamstring musculature. ADVANCED POSTOPERATIVE PERIOD An often-neglected component of performance is balance. Ligamentous sprains involve the disruption Advanced rehabilitation for the patient who will of capsular nerve endings.7 The inclusion of balance return to athletics stresses the functional and specific activities such as one-leg standing, weight shifting, aspects demanded by the sport. Those who have had and tilt board exercises is necessary if an individual extensor mechanism repair and plica excisions must is to attain his preinjury level of fitness. continue with straight leg raises and bicycling. If there Rehabilitation is not complete until each muscle of has been any type of shaving of the patellofemoral the lower extremity is equal to or greater than the surfaces, it will take at least six months for the knee opposite side in strength and flexibility (Figs. 11-15). surfaces to regenerate. To start flexion-to-extension All functional activities should be done with the same exercises before then will only invite further trauma ease and confidence that the patient possessed prior to the knee. Thus running and agility drills begin only to surgery. The status of the patient's cardiovascular after sufficient strength has been attained and tissue system must be superb if he is to participate in repair has occurred. When patients who have had a endurance activities. All running times should be meniscectomy or ligamentous repair reach a 75 per- equal to those performed before surgery. These cricent level of normal on their Cybex* isokinetic teria must be met before an individual can safely dynamometer evaluation of the quadriceps femoris return to competitive athletics. muscle and are riding the bicycle 12.5 miles (20 km) a day, advanced activities are begun with physician KNEE APPLIANCES approval. Many patients treated in physical therapy for knee problems can benefit from a supportive knee appli* Lumex, Inc, 100 Spence St, Bay Shore, NY 11706. ance. This portion of the paper gives a basic introVolume 60 / Number 12, December 1980
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Fig. 16. Palumbo Patellar Stabilzation Brace used to prevent the lateral dislocation of the patella.

Fig. 17. The Pro Dr. M. Brace used to alleviate discomfort of patellar tendinitis.

Fig. 18. The Lenox Hill Derotation Brace to compensate for knee hype rextension, varus/valgus, or rotational instabilities.

duction to the selection and fabrication of these devices and should not be considered as a complete guide to the topic. The purposes of knee appliances are as follows: 1) to protect the surgical procedure during healing of tissues, 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 increase the space between the patella and the femur). The medical and lay communities have many misconceptions about knee appliances, for example, that 1) a knee appliance will replace a thorough rehabilitation program, 2) a knee appliance will replace a conscientiously pursued strength/power maintenance program, and 3) a knee appliance is always needed after an injury. Appliance selection should be based on the following considerations: 1) there must be a definite need, 2) the appliance must not be used in a way that might injure the patient, 3) the particular device chosen must meet the established need, 4) the appliance must look reasonably attractive and feel comfortable to the patient, and 5) the cost must be affordable. The various types of appliances can be categorized by method of fabrication. Clinic fabrication includes use of such appliances as a modified Levine strap and a felt lateral-patellar stabilizer and use of tape. Commercially fabricated devices include stock models such as a Levine strap, Pro-devices, dynamic patellar stabilization braces, and cartilage braces. Commercially fabricated custom orthoses include those designed to prevent the lateral dislocation of
Jack Levine, MD, Director, Department of Orthopaedic Surgery, Brookdale Hospital Medical Center, Linden Blvd at Brookdale Plaza, Brooklyn, NY 11212.

the patella, such as the Palumbo Patellar Stabilization Brace (Fig. 16), as well as those designed to alleviate the discomfort of patellar tendinitis such as the Pro Dr. M. Brace** (Fig. 17). The reasons for using these appliances are the need for additional support for the knee joint and the attempt to save money over the cost of custom-fabricated devices. Custom-made orthoses have been available for the past several years and, although expensive, provide maximum protection for the patient's knee. These orthoses, which include the Lenox Hill Derotation Brace (Fig. 18) and the Iowa Brace, will last indefinitely if properly fitted and cared for. The Lenox Hill Derotation Brace requires the clinician to mark anatomical landmarks with a water-soluble pen on a stockinette that the patient is wearing. The patient is then casted, with the markings ultimately being transferred to the wet plaster. When the plaster cast (negative mold) is filled with plaster, the markings are transferred for a second time onto the positive mold. The orthotist then fabricates the brace over the positive mold to accommodate both for knee size and type of instability. For example, a Lenox Hill Brace may be fabricated to compensate for knee hyperextension, varus/valgus, or rotational instabilities. Our treatment programs are based on what has been successful for our patients in our clinics. Our treatment decisions have been based on empirical

P. M. Palumbo, MD, 8206 Leesburg Pike, McLean, VA 22180. * * Pro Orthopedic Devices, Inc, PO Box 1, King of Prussia, PA 19406. Lenox Hill Brace Shop, Inc, 100 E 77 St, New York, NY 10021.

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data, rather than on controlled laboratory study. Clinical research must now be done to verify our theories and procedures. This basic information regarding knee appliances and the type of problems they may alleviate is to serve only as an introduction. We hope that it will stimulate the physical therapy clinician to become more interested in evaluating patients who might benefit from these devices and consult with their physicians regarding their possible use.

SUMMARY
Knee rehabilitation is nearly as complex as the knee itself. The general and specific programs and exercises presented are to be used eclectically. Rehabilitation must not be of a cookbook nature but rather individualized to fit the needs of the patient. The emphasis of rehabilitation must be dictated by the demands the individual places upon the knee. Rehabilitation must degenerate into function!

APPENDIX Techniques of Exercise

The following exercises represent our routine techniques that are adapted according to each patient's response. The critical factor in each exercise program is for the therapist to avoid causing the patient swelling or discomfort while having him work to his maximum exercise tolerance. Quadriceps Femoris Setting Exercise: Quadriceps femoris setting is an isometric contraction of the quadriceps femoris mechanism, usually with the knee in full extension. The patient contracts the quadriceps femoris muscle, causing the patella to track proximally and the leg to be straightened as much as possible. Because this is an isometric exercise, the contraction should be held for a full six-second count. The patient performs 50 of these exercises an hour during every waking 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 foot planted flat next to the involved knee. He contracts the involved quadriceps femoris muscle and then lifts the leg up to 45 degrees. He holds the leg there for a count of two and then lowers it to the floor and relaxes it for a count of two. The knee should be at full extension throughout the lift. The quadriceps femoris muscle must be contracted and the knee held in full extension before the leg is lifted. The patient does eight sets of 10 lifts with a 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 patient begins with a weight that he can lift easily, yet that makes him tired after eight sets of 10 lifts. The knee must remain in the same amount of extension on the last lift as it did on the first, as if there were no weight at the ankle at all. This is an easy way to estimate how much weight to use on these exercises. The weight is increased according to the patient's tolerance (Fig. 2). Terminal Extension Exercise: If support is placed beneath the popliteal fossa during straight 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 knee extension, he should do minimal terminal extension exercises. Here, the support beneath the knee is just enough so that when the patient contracts the quadriceps femoris muscle as tightly as possible, the heel will clear the exercise surface by less than an inch. This encourages the patient to work harder on extending the knee and on using more motor fibers of the quadriceps femoris muscle. Fifty of these exercises are done three different times a day. Resistance can be added as necessary. The terminal kneeextension exercise can be used with the straight-leg-raise exercise. When the patient has the knee extended to its fullest amount, he can raise the entire leg up to a 45degree angle of the hip and continue the straight-leg-raise technique (Figs. 3, 4). Knee Extension Exercise: This exercise is done from 90 degrees of flexion to the fullest amount of extension. The exercise should be done with the foot resting on the floor or stool and is termed "bottomed out." (This means that if the patient sits with the legs dangling and weights attached, the ligaments of the 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 on the floor. After a two-count rest, the exercise is repeated. Eight sets of 10 are allowed. Resistance is added in much the same way as with the straight leg raise (Fig. 5). Hamstring Exercise: The patient stands with the anterior part of the thigh pressed against a wall or table to block hip flexion. He flexes the knee to its fullest position, holds it for two counts, and lowers it to the floor. The individual does four to eight sets of 10 lifts three different times a day. Resistance is added and progressed according to the patient's tolerance (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-degree angle. He holds it there for two counts and then lowers it for a two-count rest. This exercise is done in four sets of 10 repetitions three different times a day. The clinician

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can add resistance by placing a barbell plate weight on the knee and holding it with the contralateral hand, while the ipsilateral hand grasps the front of the sitting surface to prevent the patient's leaning backward (Fig. 7). Hip Abduction Exercise: The patient lies, in relation to his affected knee, on his contralateral side with his contralateral knee flexed to 90 degrees for stability. He performs a quadriceps femoris setting exercise and then lifts the leg in the frontal plane of the body. Four sets of 10 repetitions are performed three times a day with 30-second to 1-minute rests between each set. Resistance can be added at the ankle. The individual must not flex his hip during this exercise or rotate his trunk posteriorly (Fig. 8). An alternate exercise program for the hip abductor muscles can be done isometrically. A belt is strapped just proximal to the knees and the patient abducts the thigh against the belt, holding for a six-second count and then relaxing. This should be done 25 times, three different times a day. Hip Extension Exercise: The patient positions himself over a firm table or bed, with the edge of the surface at the hip joint line. From the prone position he extends his hip on the involved side with the knee in full extension to the normal amount of extension at the hip. He holds this position for two counts, lowers his leg, rests for two counts, and then repeats. Four sets of 10 repetitions are done and progressive resistance added as necessary (Fig. 9).

Hip Adduction Exercise: The easiest way to strengthen the hip adductor muscle is by an isometric exercise. The patient places a basketball or a soccer-type ball between his knees and then squeezes the ball, holding for a six-second count. This is repeated 25 times three different times a day. He may do this supine, sitting, or standing (Fig. 10). Quadriceps Femoris Stretching: The patient lies prone and pulls his heel toward his buttock. He holds for 10 counts, then releases. Five minutes of stretching is preferred (Fig. 11). Adductor Stretching: The patient sits with soles of his feet together and slides them toward the buttocks. He actively pulls his knees toward the floor and 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 flexed forward so that his top leg with knee flexed can touch floor. He holds this position for 10 counts and then releases. Five minutes of stretching is preferred (Fig. 13). Hip Flexor Stretch: The patient lies supine. He pulls one knee to his chest and extends the opposite leg as hard as possible. He holds for 10 counts, then releases. Five minutes of stretching is preferred (Fig. 14). Hamstring Stretch: The patient assumes a long-sitting position with one leg off the exercise surface. He slowly leans forwardno bouncing is allowed. He holds for 10 counts, then releases. Five minutes of stretching is preferred (Fig. 15).

REFERENCES
1. DeLorme TL: Restoration of muscle power by heavy resistance exercise. J Bone Joint Surg 27:645-667, 1945 2. Zinovieff AN: Heavy resistance exercise: The Oxford techniques. Br J Phys Med 14:29-32, 1951 3. Knight KL: Knee rehabilitation by the daily adjustable progressive resistance exercise techniques. Am J Sports Med 7:336-337, 1980 4. Noyes FR, Grood ES: Strength of the interior cruciate ligament in humans and rhesus: Age and species-related changes. J Bone Joint Surg [Am] 58:1074, 1976 5. Noyes FR, DeLucas JL, Torvic PJ: Biomechanics of anterior cruciate ligament failure: An analysis of strain-rate sensitivity and mechanisms of failure in primates. J Bone Joint Surg [Am] 56:236, 1974 6. Yamamoto SK, Hartman CW, Feagin JA, et al: Functional rehabilitation of the knee: A preliminary study. J Sports Med 3:288, 1976 7. Freeman MAR, Dean MRE, Hanham IF: The etiology and prevention of functional instability of the foot. J Bone Joint Surg [Br] 47:678-685, 1965

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PHYSICAL THERAPY

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

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