Clinical Review: Current Concepts

Kinetic Chains: A Review of the Concept and Its

Clinical Applications
Ninad Karandikar, MD, Oscar O. Ortiz Vargas, MD

During the past decade, our understanding of biomechanics and its importance in rehabil-
itation has advanced significantly. The kinetic chain, a concept borrowed from engineering,
has helped us better understand the underlying physiology of human movement. This
understanding, in turn, has facilitated the development of new and more rational rehabili-
tation strategies. The kinetic chain concept has application in a wide spectrum of clinical
conditions, including musculoskeletal medicine, sports medicine, and neurorehabilitation,
as well as prosthetics and orthotics. The purpose of this review is to provide insights into
the biomechanics related to the concept of kinetic chains, with a specific focus on closed
kinetic chains and its clinical applications in rehabilitation.
PM R 2011;3:739-745

INTRODUCTION
The concept of kinetic chain reaction originated from the German engineering scientist
Franz Reuleaux (1829-1905), who is often called the “father of kinematics.” Reuleaux first
proposed the novel “link concept” in his book The Kinematics of Machinery in 1876 [1]. The
link system concept, although initially related to engineering, has become a widely accepted
and well-reviewed principle in rehabilitation [2-5].
As proposed by Reuleaux, in a rigid-link system, pin joints connect a series of overlap-
ping rigid segments. If both ends of this system are fixed such that no movement can occur
at either end, the application of an external force causes each segment to receive and transfer
force to the adjacent segment, generating a chain reaction. As a result, movement at any joint
will produce a predictable movement pattern at all other joints in the chain (Figure 1).
The extrapolation of this conceptual framework of kinetic links or the link system to the
analysis of human movement was first introduced by Hans von Baeyer in 1933 at the
International Orthopedic Congress while he gave a synopsis of muscle function. In his work,
which focused on synergistic muscle actions in the limbs, he contrasted the effects occurring
in the limb periphery with the effects at the proximal end of the limb lever arm [6].
The kinetic chain concept was then elaborated and popularized in the rehabilitation
literature by Steindler in his book Kinesiology of the Human Body, which was published in
1955 [7]. Steindler proposed that the limbs be thought of as “rigid overlapping segments” in
series. He defined the kinetic chain as “a combination of several successively arranged joints
constituting a complex motor unit.” Each bony segment in the lower extremity, such as the
foot, lower leg, thigh, and pelvis, can be viewed as a rigid link, with the subtalar, ankle, knee, N.K. Department of PM&R, University of Ken-
and hip joints acting as the connecting joints [8]. In later writings, Steindler [7] categorized tucky, 2050 Versailles Blvd, Lexington, KY
40504. Address correspondence to: N.K.;
the kinetic chain concept as open or closed depending on the loading of the terminal (most
e-mail: nkara2@email.uky.edu
distal) segment. Disclosure: nothing to disclose

O.O.O.V. Physical Medicine and Rehabilita-

tion, Veterans Affair Medical Center Lexington,
DEFINITIONS Lexington, KY; and Department of PM&R,
University of Kentucky, Lexington, KY.
Disclosure: nothing to disclose
Biomechanics
Disclosure Key can be found on the Table of
Biomechanics is defined as the application of the mechanics of motion produced by biologic Contents and at www.pmrjournal.org
systems. The study of biomechanics requires consideration of resultant motions produced Submitted for publication December 2, 2010;
by forces. Kinetics refers to the study of forces that affect motion of a body, such as friction, accepted February 19, 2011.

PM&R © 2011 by the American Academy of Physical Medicine and Rehabilitation

1934-1482/11/$36.00 Vol. 3, 739-745, August 2011 739
Printed in U.S.A. DOI: 10.1016/j.pmrj.2011.02.021
740 Karandikar and Vargas KINETIC CHAINS

volved [9]. The nature and physiology of underlying muscle

contractions involved in performing the joint motion (eg,
isotonic, isometric, or isokinetic) are closely related but in-
dependent concepts that are not discussed in this review.
This concept of open and closed kinetic chain joint mo-
tions can be applied directly to exercises and daily activities.
Most therapeutic exercises are complex and involve a com-
bination of open and closed kinetic chain characteristics.
For the purpose of this review, we define CKC exercises as
those that resembles CKC system characteristics and OKC
exercises as those that resemble OKC system characteristics
in a specific joint targeted by that exercise.
A clinical example of an OKC exercise is the seated knee
extension leg curl (Figure 2). During this exercise, the distal
segment (the leg) is free to move in space, whereas the
proximal segments (the thigh and trunk) are fixed. With
OKC exercises, a single joint is usually the focus of the OKC
motion—the knee, in the case of the leg curl. A clinical
example of a CKC exercise is the standing squat exercise
(Figure 3). During this exercise, the feet remain fixed to the
ground and motion occurs uniformly across multiple lower
extremity joints.
In many activities of daily living and sports, the activation
sequence in the link involves a CKC whereby the activity is
initiated from a firm base of support and the resultant force is
then transferred through the links to the more mobile distal
segments. Although most activities can be classified as OKC
or CKC, in some instances this distinction is difficult to make.
For example, in swimming and cycling, which traditionally
are viewed as OKC activities, there is a load on the distal
Figure 1. In an OKC system, a force (arrow) applied to a segment, yet the distal segment is not fixed or restricted from
terminal segment (A) will cause movement to only that seg-
movement.
ment (A). In contrast, in a CKC system, the same force applied
to the segment A (now fixed) will cause movement in all Dillman [10] proposed that the classification be deter-
segments (B, C, and D). mined by whether the terminal segment in the chain is
movable or fixed and whether it bears a load. An activity with

gravity, or pressure. In contrast, kinematics is the study of the

spatial and temporal characteristics of motion without regard
to the causative forces.

Open and Closed Kinetic Chain Systems

Steindler defined an open kinetic chain (OKC) system as “a
combination of successively arranged joints in which the
terminal segment can move freely” [7]. In an OKC system,
the distal segment is therefore free to move in space.
Steindler initially defined a closed kinetic chain (CKC)
system as “a condition or environment in which the distal
segment meets considerable external resistance that prohibits
or restrains its free motion” [7]. In a CKC system, a force
applied to one of the segments produces motion at all other
segments (kinetic chain) in a predictable fashion.
It is now known that muscle recruitment and joint move-
Figure 2. Open kinetic chain exercise.
ment patterns vary based on the type of kinetic chain in-
PM&R Vol. 3, Iss. 8, 2011 741

Table 1. Characteristic properties of closed kinetic chain and

open kinetic chain exercises

Characteristics of closed kinetic chain exercises

Increased joint compressive forces
Increased joint congruency (and therefore increased
stability)
Decreased shear forces
Characteristics of open kinetic chain exercises
Increased joint distraction and rotational forces
Increased joint deformation (and therefore reduced
stability)
Increased shear forces

lected muscle groups is desired. In contrast, CKC exercises

cause co-contraction of the agonist and antagonist muscle
groups. This biomechanical difference makes CKC exercises
useful once isolated weakness is eliminated [12]. Other ben-
efits achieved with CKC rehabilitation include (1) the estab-
lishment of early proximal stability (shoulders, hips, trunk),
providing a more stable base for distal function [13] and
ambulation [14]; and (2) improvement of proprioception,
neuromuscular control, and subsequently functional stability
of the joint (Table 1) [15,16]. For example, during OKC knee
extension, the quadriceps perform most of the work related
to the motion, whereas the hamstrings are activated to con-
trol the motion without contributing significantly to the work
performed. In contrast, in a CKC system, eg, in a straight
squat, with the center of gravity placed directly over the knee,
both the quadriceps and hamstrings work simultaneously to
control knee flexion. The result is stabilization of the knee
through simultaneous activity of 2 opposing muscle groups
[17]. As the leg moves into terminal extension in OKC, the
work required to lift the leg increases because the moment
arm of the resistance force (gravity) increases. This phenom-
enon requires an increasing force production by the quadri-
Figure 3. Closed kinetic chain exercise. ceps in the terminal 30° of knee extension. This action causes
an anterior translation of the tibia, resulting in a high shear
a fixed terminal segment and no load does not exist. Consid- force across the knee. In contrast, in a CKC knee extension,
ering the variables of load and mobility of the terminal through simultaneous co-contraction of the hamstrings and
segment, all activities can be classified as one of the following: quadriceps, significantly less shear stress and increased sta-
bility occurs across the knee joint [5,17].
1. Moveable, no load (resembles an open chain system)
Lefever [8], in an excellent review, emphasizes the impor-
2. Fixed, external load (resembles a closed chain system)
tance of 2 variables in CKC exercise: (1) placement of center
3. Moveable, external load (a combination of closed and
of gravity and (2) placement of the terminal limb, especially
open chain systems)
in the lower extremity. Performing a knee flexion-extension
More recently, Kibler [11] defined a closed-chain activity movement in a CKC position can activate different muscle
as a sequential combination of joint motions in which the groups, depending on where the center of gravity is placed
distal segment of the kinetic chain meets considerable resis- in relation to the knee [8] (Figure 4). If the center of
tance but does not have to be fixed. gravity is placed directly over the knee (Figure 4, center),
the knee extensors work to control the movement,
whereas if the center of gravity is placed behind the knee
CKC AND OKC EXERCISES:
(Figure 4, left), more stress is placed on the hip extensors
BIOMECHANICAL DIFFERENCES
to control the movement. However, if the center of gravity
Open-chain exercises result in isolated movement at a given is placed in front of the knee (Figure 4, right), the gastroc-
joint and are effective when isolated strengthening for se- nemius must control the movement. Thus the position of
742 Karandikar and Vargas KINETIC CHAINS

Figure 4. Effects of moving the center of gravity over the joint axis on muscle recruitment pattern in closed kinetic chain
activity.

the center of gravity over the joint axis can directly influ- functional outcomes after anterior cruciate ligament (ACL)
ence muscle recruitment. reconstruction. The first randomized controlled trial that
Position of the terminal segment in the transverse or compared OKC exercises and CKC exercises in ACL injury
coronal plane is also important when one performs CKC was performed in 1995. It showed that CKC exercises
exercises [8]. For instance, when the foot is placed in prona- were safe, effective, and could offer the advantage of less
tion, excessive internal rotation of the entire lower limb stress on the healing graft and less patellofemoral pain
might occur, causing increased stress to the knee [18]. This [24].
stress may cause or worsen patellofemoral pain [19,20] or More recent studies have shown that CKC exercises pro-
potentially affect the healing of capsuloligamentous struc- duce less pain and laxity and better subjective outcomes than
tures around the knee [21]. do OKC exercises after ACL reconstruction [25]. It is pro-
posed that this benefit of CKC exercises results from co-
CLINICAL APPLICATIONS contraction of the quadriceps, hamstrings, and gastrocne-
mius muscles, decrease shear forces between tibia and fibula,
Despite some controversy, CKC exercises have gained popu- and increase joint compression, thus enhancing joint stability
larity over more traditionally used OKC exercises in the past and protecting the graft [26,27].
decade. Many clinicians believe that CKC exercises are more Fitzgerald [22], emphasizing a different perspective, states
functional and safer than OKC exercises because they pro- that the critical difference between OKC exercises and CKC
duce stresses that are less of a threat to healing and repaired exercises is not the kinematic arrangement but the resultant
structures [22,23]. The principle and evidence basis of CKC loads transmitted to the knee. With controlled but not ag-
exercise, as clinically applied in several areas of rehabilita- gressive training loads, OKC exercises appear to be as safe as
tion, is reviewed in the following sections. CKC exercises. This finding has led Perry and colleagues [28]
to hypothesize that the difference in outcome between CKC
and OKC exercise could be related to a difference in training
Anterior Cruciate Ligament
dose, with more intense therapy when performing CKC
Reconstruction
rehabilitation. Further complicating this issue, Mikkelsen
During the past few decades, CKC techniques have been and colleagues [29] used a combined OKC and CKC exercise
used as the rehabilitation method of choice to improve program to show greater improvement in outcomes of pa-
PM&R Vol. 3, Iss. 8, 2011 743

tients with ACL repair, which questions the validity of a scapular dyskinesias, or labral tears with repetitive motion
CKC-only rehabilitation approach. [51]. Evaluation of athletes with suspected shoulder lesions
should include tests to check kinetic chain functioning, in-
cluding a leg and back examination [51]. We hypothesize
Patellofemoral Pain Syndrome that the same concept can be applied to non-athletes in-
The realization that open and closed kinetic chain exercises volved with work-related repetitive overuse shoulder inju-
have different effects in rehabilitation of patients with patel- ries, such as manual laborers.
lofemoral pain syndrome (PFPS) started in the 1980s. Bio- The kinetic chain principle further helps the practicing
mechanical analyses have demonstrated less patella-femoral clinician to plan the appropriate rehabilitation regimen for
contact stress during knee flexion in CKC when compared the injured shoulder [5]. The rehabilitation program for
with OKC exercises [30-32]. These findings were later con- shoulder training should involve a graduated progression,
firmed with more direct approaches [33,34]. starting with non–weight-bearing isometric exercises, pro-
Early controlled trials also revealed better restoration of gressing to low-weight CKC through a pain-free motion,
function [35], making the use of CKC exercises the corner- usually in the mid range, and then progressing to weight-
stone of the treatment for PFPS in the mid 1990s [36]. In bearing OKC exercises. Along with training for muscular
more recent studies, however, investigators have revealed endurance, proprioception, neuromuscular control, and ki-
that patella-femoral stress can be equally high in both CKC netic chain training should be advanced throughout the
and OKC exercises. Compressive forces have been found to rehabilitation program [52].
be equally high in near-full flexion with CKC exercises and in
full extension with OKC exercises [37,38]. Despite all the
theoretical benefits, several high-quality randomized con- Spinal Cord Injury
trolled trials have failed to prove significant differences in
Application of the principle of CKC in persons with a spinal
outcome between CKC and OKC exercises in the treatment
cord injury can help with pressure relief, transfers, and
of PFPS [39-41].
wheelchair propulsion in patients with injuries as high as C5
Currently, most protocols recommend including a com-
[53]. The major barrier to gaining independence in perform-
bination of both CKC and OKC exercises for management of
ing daily activities in high-level quadriplegics is the lack of
PFPS [42,43]. Resistance training usually is started in the
active antigravity strength of elbow extension. The principles
acute phase with isometric OKC exercises, at 30°-45° knee
and mechanics of CKC, when used appropriately in this
flexion [44]. In the subacute phase, training can progress
patient population, can help improve independence with
gradually to short-arc OKC exercises, followed by long-arc
some activities. It involves the use of the anterior deltoid,
OKC exercises, as tolerated [45]. In the chronic phase, em-
biceps, and brachialis muscles, all innervated by the C5
phasis should be placed on CKC exercises. There is some
spinal nerve root, in a CKC to convert the regular elbow/
evidence that OKC exercises in the chronic phase might
shoulder flexion moment to an elbow extension moment
preferentially activate vastus lateralis instead of vastus medi-
when the hand is fixed on the wheelchair hand rim by
alis obliquus, which in turn may have a counterproductive
friction [53].
effect because of potential induction of excessive lateral
tracking of the patella [46].

Gait, Prosthetics, and Orthotics

Shoulder Pain
Kinetic chain principles also are applicable in the field of gait
The biomechanical model for the throwing shoulder in elite analysis and prosthetics and orthotics. The primary goal of
athletes has been extensively reviewed in a series of articles gait is energy-efficient locomotion, which is achieved by
[47-49]. In a landmark article [50], Kibler explains that using a stable kinetic chain of multiple limb segments that
shoulder function in throwing requires contributions from work congruently to transport the passenger unit (head,
all body segments to generate the forces necessary to propel arms, and trunk) on the locomotor unit (lower limbs and
the ball and pass the forces and loads to the mobile distal pelvis).
segments. This coordinated sequencing of the segments is a Gait involves 2 main phases: stance and swing. The entire
prime example of the CKC concept. In the normal kinetic stance phase of gait involves closed chain kinetics, while the
chain of throwing, the ground, legs, and trunk act as the force swing phase is all open chain. The first functional task in the
generators; the shoulder acts as a funnel and force regulator; stance phase is weight acceptance. The demand for immedi-
and the arm acts as the force delivery mechanism [49]. ate transfer of body weight onto the limb as soon as it contacts
Understanding this kinetic chain then helps to correlate how the ground requires initial limb stability and shock absorp-
a pathology such as weak core muscles, abnormal hip, or tion while simultaneously preserving the momentum of pro-
knee rotation eventually may lead to shoulder impingement, gression. When the functional task of weight acceptance has
744 Karandikar and Vargas KINETIC CHAINS

been achieved, the individual is said to demonstrate a stable ACKNOWLEDGMENTS

kinetic chain [54].
We thank Dr. Helen O’Donnell for her valuable comments
In the field of orthotics, one of the most common prescrip-
regarding the manuscript and Raquel Nazario for her help
tions in physiatric practice is the ankle foot orthosis. The
with the photos.
rationale behind using an ankle foot orthosis for quadriceps
weakness can be explained easily with the principle of CKC
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