Criteria-Based Decision Making for Introducing Open Kinetic Chain Exercise after-ACL Reconstruction: A Scoping Review

Background: After an anterior cruciate ligament reconstruction (ACLR), mounting evidence suggests that open kinetic chain (OKC) strengthening is safe, reduces the risk of anterior knee pain, and significantly improves the quadriceps strength. However, clinicians are reluctant to use OKC knee strengthening exercises mainly due to the strong beliefs that they might increase graft laxity. The objective of this scoping review is to identify the key criteria employed in the scientific literature for the safe introduction of OKC quadriceps strengthening following ACLR. Methods: A scoping review of the literature was conducted on the online databases MEDLINE (PubMed), ScienceDirect, Embase and CINAHL Library online. Data regarding time-based criteria and/or clinical based criteria allowing OKC exercises introduction following ACLR were searched for. Only studies involving patients who performed quadriceps strengthening using any type of OKC exercises were included, regardless of the type, resistance location, load magnitude, type of muscle contraction, knee range of motion, or duration of the strengthening protocol. Results: Twenty-six studies met the inclusion criteria. Twenty-one employed time-based criteria for the introduction of OKC exercise. The median time from when OKC was permitted was 15 postoperative days (range 1–270 days), while the mean time was 31.6 ± 56.7 postoperative days. In 30.7% of the studies additional clinical examination components were used. These components included range of motion (0-100°), numeric pain scale score < 2 or 3, absence of joint effusion (assess by the stroke test), full knee active extension (assess by the straight leg raise), and walking without crutches for the decision-making regarding OKC exercise introduction. Conclusion: Less than one study in 3 reported clinical criteria for the introduction of OKC exercise. This highlights the absence of consensus among surgeons and physiotherapists, thereby hindering their ability to make informed decisions based on scientific evidence. Although the use of OKC exercise appears to be safe, precautions to maintain the integrity of the surgical repair need to be implemented. The establishment of valid criteria is crucial to support evidence-based decision-making. © The Author(s) 2025.; Open kinetic chain (OKC) exercises are generally safe and can significantly improve quadriceps strength without increasing the risk of graft laxity after anterior cruciate ligament reconstruction (ACLR). The majority of studies (80.7%) used time-based criteria for introducing OKC exercises, with a median time of 15 postoperative days. Combining clinical and temporal criteria ensures safe and effective integration of OKC exercises in ACLR rehabilitation. © The Author(s) 2025.