The Open Chain U-Turn.
Why I now start open chain work in week one
Last night I had the absolute privilege of sitting in on a Q&A and brainstorming session with the head physios from across the Super Netball league here in Australia.
Huge shout-out to Ali Low for pulling it all together as it was one of those nights where you walk away buzzing, scribbling notes, thinking right, I need to write this down before I forget half of it.
So here we are.
One of the questions that really got me thinking was about open chain knee extensions.
When do I bring them in?
How early?
How heavy?
And how do you have those conversations with surgeons or senior clinicians who’d still rather you didn’t?
Before I dive in, a quick aside that I think matters. Whether you’re working in an elite setting or with the postie who busted their ACL playing social futsal on a Wednesday night, the principles are the same.
A knee is a knee.
The trauma’s the same.
The surgical procedures are largely the same.
The graft types are largely the same.
What differs is the support around the person and the resources, the timelines, the goals, the psychological scaffolding; not the rehab principles themselves.
Okay. Onto the good stuff.
Confessions of a recovering open-chain-phobe
Let me start with a bit of honest reflection.
Through my undergrad, and well into my early years as a clinician, open chain exercises were framed as essentially evil. Disastrous for the graft. Stretchy, dangerous, “wait at least three months, maybe six, definitely don’t do them on day five.” If I did them at all, it was late, cautious, and often after the horse had bolted - by which point my patient was already wrestling with anterior knee pain, recurrent swelling, or a quad that had basically gone on permanent leave.
What changed?
A few things.
Reading the strain literature properly (Escamilla and colleagues 2012 is your friend here). Talking to ACL clinicians and researchers who’ve been using open chain confidently for years without graft failures piling up. And embarrassingly, actually doing the maths on the strain values during exercises I was happily prescribing every day, like walking and squatting.
It turns out the closed chain exercises I was telling people were “safe” were straining the graft more than the open chain ones I was telling them to avoid.
Walking, just normal, restored-gait walking, strains the ACL graft around 13%. Sitting on the edge of a plinth and kicking the knee up against gravity? About 2.5%.
So you can see where this is going.
The rest of this post is for paid subscribers of The ACL Hub. If you want the full open chain protocol - early isometrics setup, when isotonics come in, how I dose load without expensive tech, the Forelli 2023 paper that changed my mind, how to have the surgeon conversation respectfully, and my favourite low-tech trick for cutting through quad inhibition - come and join us below.
