Robert Panariello MS, PT, ATC, CSCS
Founding Partner, Chief Clinical Officer
Professional Physical Therapy
New York, New York
The rehabilitation of the injured or post-operative ACL reconstructed (ACLr) knee athlete presents with many challenges. Two of these challenges include re-establishing the muscle activity and strength of the quadriceps muscle group in the manifestation of arthrogentic muscle inhibition and the restoration of full knee extension (both passively and actively). Preliminary treatment methods to achieve these objectives are available utilizing both open kinetic chain (OKC) and/or closed kinetic chain (CKC) exercise model activities. OKC exercises have been shown to place increased strain upon the ACL graft in the terminal (10 – 30 degrees) end of knee range of motion (ROM) thus CKC exercise is an alternative consideration when prescribing terminal knee ROM activities during the early rehabilitation stages. One initial CKC exercise method that has successfully endured the test of time is what has been commonly known as the DonTigny or “Tigny” exercise. DonTigny developed a sequence of terminal knee extension exercises that were initially published, to my knowledge, almost 50 years ago (1).
The Tigny CKC exercise is prescribed in the standing full weight-bearing position. The standing weight-bearing position provides the additional benefits of CKC exercise to protect the ACL graft including knee joint stability via joint compressive forces as well as the “mechanical” locking that occurs at the knee when approaching full terminal extension. The Tigny exercise is performed with the application of an external resistance (i.e. Theraband, a Velcro cuff with an attachment to a cable column, etc.) placed around the knee at the level of the popliteal fossa. The athlete then assumes a standing approximate 30 degree flexed knee posture while assuming a flat foot weight-bearing position. While maintaining this flat foot position the patient extends their knee by contracting their quadriceps muscles in an attempt to achieve full knee extension (figure 1). The exercise may also be performed with the application of electric stimulation prescribed with an appropriate work to rest ratio for additional “overload” or with an audio and/or visual biofeedback unit to assist to ensure an optimal neuromuscular controlled quadriceps contraction.
Figure 1 The DonTigny Exercise
Our progression of the Tigny exercise includes the elevation of the heel of the exercising lower extremity. It is important to note that terminal knee extension in the CKC position may also be achieved with the synchronized contraction of both the hamstring and gastrocnemius muscle groups. Due to the respective specific attachments at the knee, the muscle contraction force of the distal hamstring in conjunction with the proximal gastrocnemius will produce a knee extensor resultant force (figure 2).
Figure 2 Hamstring and Gastrocnemius Muscle Group Resultant Force
As the gastrocnemius is a contributor to this CKC knee extension exercise, the raising of the heel (ankle plantar flexion) upon a low block or half foam roller will shorten the muscle to assist to reduce the contribution of the gastrocnemius from the “knee extension equation”. A plantar flexed ankle position will shorten the gastrocnemius favoring the muscle toward a condition of “active insufficiency”. This active insufficiency will result in a reduction in the contribution of the gastrocnemius muscle force during the exercise performance, therefore requiring a more emphasized and required forceful contraction of the quadriceps muscle group to achieve the desired full knee extension against the prescribed external resistance (figure 3).
Figure 3 The Starting and Concluding Tegney Exercise with Heel Elevation
Try this early rehabilitation phase DonTigny CKC quadriceps exercise yourself. Perform the exercise with an applied resistance with the foot placed flat upon the ground surface and then again with the heel elevated. Which exercise sceniaro (heel position) do you find places a greater emphasis upon the voluntary quadriceps muscle contraction?
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- DonTigny RL, “Terminal Exercises for the Knee”, Phys Ther 52:45, 1972