A Comparison of Closed Kinetic Chain and

Isokinetic Joint Isolation Exercise in Patients

With Patellofemoral Dysfunction
Henry A. Stiene, M D '
Tony Brosky, PT, SCS
Mark F. Reinking, MS, PT, A T C ~
john Nyland, MD, PT, ATC4
Mary Beth Mason, PT, ATC5
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frequent complaint Recently, there has been attention to the clinical application of closed kinetic chain and
brought to physicians, joint isolation exercise. Our purpose was to compare the effect of joint isolation and closed kinetic
physical therapists, and chain exercise on quadriceps muscle performance and perceived function in patients with
athletic trainers is ante- patellofemoral pain. Twenty-three patients participated in an 8-week training period and were
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

rior knee pain. The assigned to either a closed kinetic chain or a joint isolation exercise training group. An 8-inch
proposed causes of such pain include (20.3 cm) retro step-up test was performed at baseline, 8 weeks, and I year. Seated knee extension
patellofemoral malalignment, overuse testing was measured at baseline and at 8 weeks using peak concentric torque on an isokinetic
injuries, trauma, osteochondral de- dynamometer at 90°/sec, 180Ysec, and 360Ysec. Perceived functional status was rated as
fects, meniscal pathologies, plical irri- excellent, good, fair, or poor based on questionnaire response. Statistical analysis showed that both
tation, ligamentous laxity, and muscle groups had significant improvement in peak torque at all speeds, but only the closed kinetic chain
length or strength imbalances (2,4- group showed significant improvement in closed kinetic chain testing and perceived functional
6,10,12,20). Initially, nonoperative status. We concluded that closed kinetic chain training may be more effective than joint isolation
management of this problem is rec- exercise in restoring function in patients with patellofemoral dysfunction.
Journal of Orthopaedic & Sports Physical Therapy®

ommended unless intra-articular le- Key Words: muscle strength, patellofemoral pain, kinetic chain
sions, such as osteochondritis disse-
cans or a loose body, exist (2,5,6).
' Internal Medicine Physician, Fellowship in Sports Medicine, Specialty Centers for Orthopedic and Rehabili-
tative Excellence, Indianapolis, IN. At the time of this study, Mr. Stiene was a team physician, University of
Conservative patellofemoral rehabili- Kentucky, Lexington, KY.
tation is suggested to include lower * Sports Physical Therapy Coordinator, University of Kentucky Sports Medicine Center, The Kentucky Clinic,
extremity stretching, quadriceps Lexington, KY
strengthening, orthotic fabrication, ' Physical Therapist, St. Francis Hospital and Health Centers, Indianapolis, IN
anti-inflammatory medication, cryo-
' Research Director, University of Kentucky Sports Medicine Center, K437, The Kentucky Clinic, Lexington,
KY 40536
therapy, activity modification, and Staff Physical Therapist, University of Kentucky Sports Medicine Center, The Kentucky Clinic, Lexington, KY
knee bracing or taping (1,2,5,9,13,
17.19).
Several authors have recom- nonfunctional because they lack the forces during isokinetic knee exten-
mended quadriceps strengthening joint proprioception, tibio-femoral sion exercise ranged from 4.9 to 5.1
with an emphasis on the vastus medi- compression forces, and synergistic times body weight. Steinkamp et al
alis obliquus (8,9,13,19). Knee exer- muscular cocontractions common to (16) reported that knee moments,
cises suggested include joint isolation athletic movements. Open kinetic patellofemoral joint reaction forces,
exercises with the distal segment free chain joint isolation exercises also and patellofemoral joint stresses were
and closed kinetic chain exercises reportedly produce higher patel- greater in knee extension exercises in
with the distal segment fixed. Open lofemoral joint compression forces functional ranges of motion as com-
kinetic chain joint isolation exercises, (7,14,16,18). Using a mathematical pared with the closed kinetic chain
such as isotonic and isokinetic knee model, Kaufman et al (11) predicted leg press exercise. Doucette and
extension, have been described as that peak patellofemoral compression Child recently reported that closed

Volume 24 Number 3 September 1996 JOSFT


NAME:
Never
After or during moderate sport activity
2) How often does your knee visibly swell?
Never
After or during moderate sport activity
3) Does your knee get stiff?
Never
After or during moderate sport activity
4) Do you feel painful grinding or "crunching" when you move your knees?
Never
After or during moderate sport activity
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5) Do you feel a painful "popping" when you move your knee?
Never
After or during moderate sport activity
6) Does your knee partially give way or buckle?
Never
After or during moderate sport activity
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
7) Does it ever feel like your kneecap is slipping out of place or will if you would let it?
Never
After or during moderate sport activity
8) Do you have problems twisting or pivoting (turning) on your knee?
Never
After or during moderate sport activity
Journal of Orthopaedic & Sports Physical Therapy®
9) Do you have problems squatting?
Never
After or during moderate sport activity
10) Do you have problems going down stairs?
Nwer
After or during moderate sport activity
11) Do you have problems going up stairs?
Never
After or during moderate sport activity
12) Do you have problems jumping or landing on your knee?
Never
After or during moderate sport activity
13) Are you able to jog or run?
Never
After or during moderate sport activity
14) How long has your knee been bothering you?
Less than 1 month
4-6 months
1 year-2 years
TABLE 1. Patellofernoral closed chain study initial questionnaire.
JOSPT Volume 24 Number 3 September 1996
RESEARCH STUDY
kinetic chain positions demonstrated
Date
improved patellofemoral congru-
ence (3).
Minimal Closed kinetic chain exercises are
Always, including at rest believed to be more desirable in
lower extremity rehabilitation be-
cause of the functional nature of the
Minimal exercise, including multi-joint action,
Always, including at rest normal proprioceptive input, muscu-
lar cocontraction, and decreased t i b
ial translation (7,14,16,18). Using
Minimal
Always, including at rest
normal healthy subject.., Reynolds et
al (15) examined a 6-week progres-
sive lateral stepup training protocol
Minimal and found no increase in quadriceps
Always, including at rest muscle performance as measured by
isokinetic peak torque. Worrell et al
(19) showed that a resisted lateral
Minimal stepup training protocol resulted in
Always, including at rest improved closed kinetic chain muscle
performance measures while no in-
crease in isokinetic quadriceps peak
Minimal
Always, including at rest
torque was observed. The primary
purpose of this study was to compare
the effect of joint isolation isokinetic
Minimal exercise and closed kinetic chain ex-
Always, including at rest ercise on quadriceps muscle perfor-
mance as measured by isokinetic
peak torque and a retro stepup test
Minimal in patients with patellofemoral pain.
Always, including at rest A secondary purpose was to compare
the effect of joint isolation isokinetic
exercise and closed kinetic chain ex-
Minimal
Always, including at rest
ercise on the patients' subjective rat-
ing of knee function.
Minimal METHODS
Always, including at rest
Subjects
Minimal All patients treated at the Univer-
Always, including at rest sity of Kentucky Sports Medicine
Center, Lexington, KY, from October
1990 to May 1992 for an acute exac-
Minimal
Always, including at rest
erbation of patellofemoral pain, but
without other knee injury, were se-
lected as potential subjects. An acute
Minimal exacerbation was defined as pain
Always, including at rest which had an onset no more than 4
weeks prior to physician evaluation.
Subjects were examined by a physi-
2-3 months cian (primary investigator) and ex-
6 months-1 year cluded if any of the following condi-
more than 2 years
tions existed: 1) under 11 years old,
2) history of prior knee surgery other
 RESEARCH S T U D Y..
Questions 1-13
Never 4 points
Minimal 3 points
After or during moderate sport 2 points
activity
Always, including at rest 1 point
Rating
- .. categories:
TABLE 2. Questionnaire scoring.
than arthroscopy for lateral retinacu-
lar release or removal of symptomatic
plica, 3) concomitant ligamentous
injury, or 4) long bone fracture. Thir-
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ty-three people fit the inclusion crite-
ria and were assigned to either group
I (joint isolation isokinetic knee ex-
tension training) or group I1 (closed
kinetic chain training). Subjects com-
pleted informed consent before entry
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
into the study.
Testing Procedures
All subjects were referred to
physical therapy following diagnostic
evaluation by the primary investigator
and completion of a subjective func-
tional questionnaire (Table 1). Based
Journal of Orthopaedic & Sports Physical Therapy®
on the score of the questionnaire, a
designated rating group (excellent,
good, fair, poor) was assigned (Table
2). Subjects were assigned to either
group by the primary investigator,
with attempts made to balance the
number of subjects with differing rat-
ings in each group. Seven subjects in
this study had experienced acute pa-
tellar dislocations. These subjects did
not complete the functional question-
naire because it was not considered a
reliable measure of their baseline
functional capability because of the
traumatic onset of their injury. Since
they did not complete the baseline
questionnaire, these subjects did not
participate in the questionnaire por-
tion of this study. These subjects did,
however, participate in the joint isola-
tion or closed kinetic training and
testing portions of this study. Four
acute patellar dislocation subjects
were placed in group I and three
were placed in group 11.
Patients were tested using an iso-
kinetic dynamometer (Biodex Corpo-
ration, Shirley, NY) for concentric
knee extensor isokinetic peak torque
between 0 and 90" of knee flexion at
90°/sec, 180°/sec, and 360°/sec.
Testing procedure began with a
5-minute warm-up on a stationary
bicycle followed by stretching of
quadriceps, hamstrings, iliotibial
band, and calf musculature. Position-
ing on the dynamometer was accord-
ing to manufacturer's protocol for
seated knee extensor testing. Patients
were instructed to perform three
warm-up repetitions at each speed,
gradually increasing their contraction
force. Testing was then completed
with five repetitions at 90°/sec, 10
repetitions at 180°/sec, and 15 repe-
titions at 360°/sec. Peak torque was
recorded at each testing speed. The
retro stepup test (6) was performed
using an &inch (20.3 cm) step. Pa-
tients were instructed to stand on the
step with the uninvolved leg and to
lower the contralateral leg to the
floor while maintaining a level pelvis
with hands on hips. A heel tap was
allowed on the floor, but no push-off
with the foot or prolonged weight
bearing was allowed. The maximal
number of consecutive retro stepups
according to patient tolerance was
recorded. Criteria used to stop the
test included completion of 50 repeti-
tions, loss of balance, inability to
complete full repetition, prolonged
weight bearing with foot on the floor,
or push-off with foot on the floor.
This same procedure was completed
with the involved leg.
The retro stepup and isokinetic
tests were repeated at 8 weeks, and
the retro stepup test was completed
again at 1 year. The functional ques-
tionnaire was completed at baseline,
6 months, and 1 year.
Training Procedures
During the first week of treat-
ment, all subjects received instruction
in ice massage and muscle stretching
exercises and were directed to con-
tinue these throughout the training
period. All subjects were also directed
to continue any current physical ac-
tivity they had been doing but not to
start any new exercise program dur-
ing the training period. Beginning
with the second week, each group
began their specific form of exercise.
Group I performed velocity spectrum
training on an isokinetic dynamome-
ter from 180°/sec to 360°/sec in
30°/sec increments. Two sets of 10
repetitions were performed at each
speed with a 20-second rest between
sets and a 60-second rest between
speeds. Subjects trained 3 days/week
for the duration of the &week train-
ing period. The accommodating re-
sistance and visual feedback of isoki-
netic exercise in addition to verbal
encouragement was considered its
own progression.
Subjects in group I1 began their
rehabilitation program with double
leg squats (0-45") and 4inch (10.2
cm) lateral and retro stepups. Three
sets of 10 repetitions of each exercise
were performed. Exercises were com-
pleted with supervision 3 days/week
for the &week training period. S u b
jects were progressed to holding
dumbbells during all exercises when
they could complete 30 repetitions
without pain or technique compro-
mise. Dumbbell resistance was started
with 2 Ibs (.91 kg) and progressed by
2-lb (.91 kg) increments to a maxi-
mum of 10 Ibs (4.54 kg). When pa-
tients could complete 30 repetitions
with 4.54 kg resistance, they were
progressed to the StairMaster 4000
(StairMaster Exercise Systems. Tulsa,
OK). Subjects began training on the
StairMaster at level 3 for 5 minutes in
"Pike's Peak" program. Training was
increased by 5 minutes at each suc-
cessive visit until 20 minutes were
reached. Subjects continued to train
3 days/week and if the subject com-
pleted a 20-minute workout without
pain or technique compromise, they
were progressed to the next training
level of the "Pike's Peakn program.
Volume 24 Number 3 September 1996. JOSPT

Age
Group (Yean 2 SD)
TABLE 3. Description of subjects.
All subjects in group I1 had p r e
gressed to the StairMaster by week 8.
Hand rails were used for balance
only. Subjects from either group had
to complete at least 70% of sched-
uled training to be included in data
analysis (Table 3).
Statistical Analysis
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A one-way analysis of variance for
repeated measures was used to ana-
lyze the retrmtep and peak torque
data; post hoc analysis was performed
using the Tukey test. A chi-square
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
analysis was used to evaluate the re-
sults of the functional questionnaire.
The significance level was set at P 5
.05.
RESULTS
Of the 33 persons beginning the
study, 23 completed the study
Journal of Orthopaedic & Sports Physical Therapy®
through the 1-year follow-up. Ten
people (six in group I, four in group
11) were excluded from the study be-
cause of noncompliance with training
or unavailability for final testing. Re-
fer to Table 3 for the demographics
of the 23 patients included in the
statistical analysis.
Summaries of retro stepup data
are presented in Tables 4 and 5. For
the involved leg (Table 4), there was
no significant difference between the
two groups for retro stepup perfor-
mance at the beginning of the study.
TABLE 4. Involved leg retro-step repetitions in groups
I and I1 at baseline, 8 weeks, and 1 year (tSDI.
JOSFT Volume 24 Number 3 September 1996
RESEARCH STUDY
Male Female OveralII Patellofemoral Grqup: Baseline 8 weeks
Subjects Subjects SYmlItom Duration lwkinetlc Speed
(M (M -onths SD)
:M Group I: 90°/sec 1 I /.I f YWJ I 11.3 f LU
1 Group It: 90°/sec 117.4 78.1 + +
157.9 33.7
3 Group I: 180°/sec 87.7 73.0 + +
132.9 23.4
Group ll: 180°/sec 89.1 59.2 + 121.3 + 25.6
Group I: 360°/sec +
91 .O 26.1 +
96.6 23.4
Grow II: 360°/sec 81.3 25.6 + +
82.8 22.8
Group I showed no significant differ- TABLE 7. Uninvolved leg isokinetic knee extension
ence between the baseline, &week, concentric peak torque values in groups I (N = 1 1 )
and 1-year values for retro stepup +
and I1 (N = 12) at baseline and 8 weeks (Nm SDI.
performance on the involved leg.
Group I1 did show a significant im- The isokinetic test results (Tables
provement in retro stepup perfor- 6 and 7) showed a significant in-
mance between baseline and 8 weeks crease in peak torques from pretest
as well as between 8 weeks and 1 to posttest for the involved (Table 4)
year. Also, group I1 scores were sig- and uninvolved legs (Table 7) at
nificantly higher than group I at 8 90°/sec, 180°/sec, and for the in-
weeks and 1 year. For the uninvolved volved leg at 360°/sec. There were
leg (Table 5), group I1 scored signifi- no significant differences between
cantly higher than group I at the be- group I and group I1 for any of the
ginning of the study, at 8 weeks, and isokinetic tests.
at 1 year. There was a significant dif- Chi-square analysis of the remain-
ference for group I between baseline ing subjects in groups I (Table 8)
and 1 year and between all three and I1 (Table 9) showed a significant
data collection points for group 11. difference between the sampling peri-
Overall, the closed kinetic chain
training performed by group I1 prob-
ably enhanced retro stepup perfor-
mance at the &week and 1-year sam-
pling periods. The differences in
baseline uninvolved leg retro stepup
performance cannot be accounted
for in this study.
Sub Pearson chi-square = 1.54.
Group jec?s Baseline 8 weeks 1 year df = 4.
p = 0.819.
I .5 + 6.5 4.4 + 6.9 6.5 + 6.5 TABLE 8. Chi-square analysis for questionnaire data
at baseline, 6 months, and 1 year. Group I is
11 12 20.5 + 11.6 26.6 + 2.2 32.1 + 9.9
without patellar dislocation subjects.
TABLE 5. Uninvolved leg retro-step repetitions in
groups I and I1 at baseline, 8 weeks, and 1 year.
Group:
Baseline 8 weeks
lsokinetic Speed
Group I: 90°/sec +
101.5 81.9 155.9 t 19.6
Group II: 90°/sec 107.0 t 69.1 148.5 + 31.0
Group I: 180°/sec 75.8 t 62.3 118.2 2 20.3
Group II: 180°/sec 82.8 2 54.7
116.1 + 25.8 Pearson ch,-square= 17.86,
Group I: 36Oo/sec 65.3 t 36.2 82.7 2 24.2
df = 6.
Group II: 360°/sec 63.0 t 30.5 78.7 + 23.0
p = 0.0066.
TABLE 6. Involved leg isokinetic knee extension TABLE 9. Chi-square analysis for questionnaire data
concentric peak torque values in groups I (N = 1 I) at baseline, 6 months, and 1 year. Group I1 is
+
and I1 (N = 12) at baseline and 8 weeks (Nm SD). without patellar dislocation subjects.
 RESEARCH STUDY

improved in isokinetic muscle perfor- knee extension, and straight leg rais-
Rating 6 months 1 year Total mance but improvements were not ing (2,5,19). More recently, advocates
Catenorv
observed in closed kinetic chain func- of closed kinetic chain exercise have
Excellent 0 0 0
Good 2 4 6 tion or in perceived functional status. recommended exercises, such as dou-
Fair 8 6 14 Previous closed kinetic chain ex- ble and single leg squats, leg press,
Poor 1 1 2 ercise studies have been published by and step-ups (1,7,14,17,19).
Total 11 11 22 Reynolds et al (15) and Worrell et al Steinkamp et al (16) conducted a
-

Pearson chi-square = 0.9524. (18), but these studies were con- study comparing the biomechanics of
df = 2. ducted on healthy university students. joint isolation knee extension exer-
p = 0.6212. Both Reynolds et al (15) and Worrell cise and closed kinetic chain leg
TABLE 10. Chi-square analysis for questionnaire data et al (18) concluded that there was press. They found that the knee mo-
at 6 months and I year. Group I: All subjects. no change in isokinetic muscle per- ments, patellofemoral joint reaction
formance following a lateral stepup forces, and patellofemoral joint
ods in group I1 but no significant training session, but Worrell et al stresses were "significantly greatern
difference in group I. With the inclu- (18) did find significant improve- during joint isolation knee extension
sion of the patients with acute patel- ment in closed kinetic chain muscle exercise than during closed kinetic
lar dislocations, a comparison of the performance as measured by leg chain leg press exercise from 0 to 30"
Downloaded from www.jospt.org at on September 30, 2018. For personal use only. No other uses without permission.

questionnaire results at 8 weeks and of knee flexion. They also found that
1 year show no difference in group I at greater flexion angles (60 and
(Table 10) but a significant differ- 90°), the three measured parameters
ence in group I1 (Table 11). Group I patients were greater during the leg press ex-
ercise. Although the exercises used in
improved in isokinetic this study were not identical to those
DISCUSSION
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

muscle performance described by Steinkamp et al, it

There is a paucity of published
literature comparing joint isolation
exercise and closed kinetic chain ex-
ercise using a patient population. It
was our purpose to compare these
exercise modes in patients with patel-
lofemoral pain regarding joint isola-
tion muscle performance, closed ki-
Journal of Orthopaedic & Sports Physical Therapy®
should be noted that all of the closed
but improvements kinetic chain exercises used in this
investigation involved knee flexion of
were not observed in less than 60". Consequently, patel-
closed kinetic chain lofemoral forces may have been at-
tenuated in the group I1 exercises as
function or compared with the forces experi-
enced by the group I subjects in joint
in perceived

netic chain muscle performance, and isolation isokinetic knee extension

perceived functional status. From our functional status. exercise. Kaufman et al (11) have
results, it can be concluded that pa- described patellofemoral forces rang-
tients performing closed kinetic ing from 5.1 to 4.9 times body weight
chain training using lateral step-ups, press, stepups, hop for distance, and at isokinetic speeds from 60°/sec to
retro stepups, double leg squats, and hop for time. Although the patients 180°/sec. Such stresses on compro-
the StairMaster 4000 show improved in this study performed additional mised tissues around the knee may
closed kinetic chain and joint isola- result in persistent inflammation that
exercises other than a lateral step-up,
tion scores and improved perceived affects functional status. Our results
our results concur with those of Wor-
functional status. Group I patients lend support to this hypothesis as the
re11 et al regarding improved closed
patients who used closed kinetic
kinetic chain muscle performance. chain training methods showed sig-
However, our results differ in that nificant perceived functional im-
Rating 6 months 1 year Total
Catwry the patients in group I1 also demon- provement as compared to the group
Excellent 1 7 8 strated improvement in isokinetic who trained with joint isolation exer-
Good 7 3 10 muscle performance.
Fair 4 2 6
cise.
Historically, quadriceps strength- Another factor which may have
Poor 0 0 0
Total 12 12 24 ening has been advocated for patel- affected our results is the difference
lofemoral dysfunction (l,2,5,17,19). in the nature of joint isolation exer-
Pearson chi-square = 6.77.
df = 2.
Exercises described for quadriceps cise and closed kinetic chain exer-
p = 0.0339. strengthening have included joint cise. While joint isolation exercise
TABLE 11. Chi-square analysis for questionnaire data isolation exercises, such as the seated allows for isolated quadriceps muscle
at 6 months and I year. Group 11: All subjects. knee extension, short arc terminal strengthening, it does not address

Volume 24 Number 3 September 1996 JOSPT


the other muscles involved in lower
extremity function. Our results show
that the patients in group I (joint
isolation) exhibited improved isoki-
netic quadriceps muscle performance ing method. Both groups improved
but showed no change in perceived
functional status. As lower extremity
function in daily weight-bearing activ- The closed kinetic chain training
ities involves multiple muscle groups
acting in synergy, it can be deduced
that rehabilitation in a weight-bearing muscle performance and perceived
position may have greater carryover
to functional activities (14).
Weaknesses of this study include
the use of a heterogenous patient
population with respect to diagnostic
groups and age and from only a sin-
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gle site in the Midwest. However, we
feel that this represents the diversity patellofemoral dysfunction.
in clinical populations and adds
strength to the external validity of
this study. From the demographic
data (Table 3). it should be noted
Copyright © 1996 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
that the two groups had a different
proportion of male to female as well
as a different duration of symptoms.
The closed kinetic chain training
group was the group with fewer
males and longer overall symptom
duration which would conceivably
deem it less favorable; however, this
was the group that exhibited greater
Journal of Orthopaedic & Sports Physical Therapy®
improvement. We also acknowledge a
small sample size ( N = 23) and rec-
ognize that this may have affected a
large variability in the results. There
is a need for future research in this
area with greater and more diverse
patient populations to further ex-
plain the different modes of both
training and testing in patients with
patellofemoral dysfunction.
CONCLUSION
This study compared closed ki-
netic chain training and joint isola-
tion training on muscle performance
and perceived functional status in
patients with patellofemoral dysfunc-
tion. The retro stepup was used as a
closed kinetic chain method for test-
ing, and training included lateral
-
JOSPT Volume 24 Number 3 September 1996
stepups, retro stepups, double leg
squats, and StairMaster exercise. Is*
kinetic knee extension was used as
the joint isolation testing and train-
in isokinetic muscle performance fol-
lowing the &week training period.
group, however, showed significant
improvements in closed kinetic chain
functional status, whereas no change
was noted in these parameters in the
joint isolation training group. We
concluded that closed kinetic chain
training may be more effective than
joint isolation exercise in restoring
perceived function in patients with
JOSPT
ACKNOWLEDGMENTS
The authors thank Janet
Wigglesworth, PhD, Director of Cen-
ter for Educational Studies, National
Institute for Fitness and Health, Indi-
anapolis, IN, for her assistance with
the statistical analysis in this study.
The authors also thank StairMaster
Exercise Systems, Tulsa, OK, for loan-
ing the StairMaster used in this study.
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