Impact of Russian Current Combined With Close and Open

Kinetic Chain Strengthening Exercises on ACL Revision

Reconstruction Using Allograft - A Case Report
Affiliations
Rohit Dawande1, Dr. Manibhadra Panda1,*, Dr. Tabish Fahim2, Dr. Ashwin Kshirsagar2, Dr.
Rohit Bhavthankar3, Akash Tandale4, Mayuresh Padalkar4, Vaishnavi Patil5, Janhavi Phatak5,
Sakshi Gujarathi5
*,1
Department of Sports Physiotherapy, MGM School of Physiotherapy, MGMIHS, Aurangabad, India
2
Department of Sports Physiotherapy, MGM School of Physiotherapy, MGMIHS, Aurangabad, India
3
Department of Sports Physiotherapy, MGM School of Physiotherapy, MGMIHS, Aurangabad, India
4
Department of Sports Physiotherapy, MGM School of Physiotherapy, MGMIHS, Aurangabad, India
5
Department of Sports Physiotherapy, MGM School of Physiotherapy, MGMIHS, Aurangabad, India

Abstract
Introduction: Primary anterior cruciate ligament (ACL) restoration has been found to be a successful
intervention with majority of patients experiencing functional recovery and good to exceptional clinical
results in post-operative evaluations. Appropriate physiotherapy management is pivotal in the post-
reconstruction phase to lower the risk of problems such as edema, pain, decreased joint range of motion,
muscular weakness, muscle girth, poor balance and impaired functional activity.
Method: A 23-year-old recreational football player with post-surgical case of recurrent left ACL
reconstruction came to sports physiotherapy department for rehabilitation. The recurrence was managed by
arthroscopic ACL revision reconstructive surgery using tibialis posterior allograft. In this case study, we
evaluated the patient’s pain, range of motion, strength of the muscles and muscles girth. In adherence to
ACL rehabilitation protocol, we used Russian current combined with various closed and open kinetic chain
exercises for improving range, thigh and leg muscles girth and also for improving the strength of thigh
muscles. We also provided MFR to the lower limb muscles every alternate day, with patellar mobilization to
increase range of motion along with strengthening of hamstring, quadriceps and calf. After that we used
vigorous lower limb and core strengthening program with balance and proprioception training along with
agility and plyometric training.
Result: We compared the pain, range of motion, strength and muscles girth before and after rehab and found
a significant improvement after 6 months.
Conclusion: Application of Russian current was effective for pain reduction and helped in strengthening of
the muscles up-to four weeks. We initially used closed kinetic chain strengthening exercises for first two
weeks followed by open kinetic chain strengthening exercises, in further progression vigorous strengthening
and endurance training of lower limb and core muscles, balance and proprioception, agility and plyometrics
training provided a patient very good recovery and improvement in overall functional capacity of the patient
after 6 months of rehabilitation.

Key words: ACL revision reconstruction, allograft, Russian current, open kinetic chain
exercises, closed kinetic chain exercises.
INTRODUCTION
Primary anterior cruciate ligament (ACL) restoration has been found to be a successful intervention, with
majority of patients experiencing functional recovery and good to exceptional clinical results in post-op
evaluations. Although, it has been observed that the professional footballers can rejoin their sport following
the reconstructive surgery, only 67% of them were capable of competing at the highest level, 3 years
following the operation. Additionally, contralateral ACL tears are infrequently found in the literature. It is to
be noted that the first two years after an ACL reconstruction are crucial, as ipsilateral graft failure is most
likely to happen during this period [1]. The prevalence of a third ACL injury in the general population
ranges from 4 to 13%. To enhance functional results and regain joint stability, an ACL repair is advised
[1].According to reports, there are 36.9 to 60.9 anterior cruciate ligament (ACL) ruptures per million person-
years, 10 to 20% of which are repeat rupture [2].
Allograft tissue has come to be accepted as a viable alternative for use in revision surgery, but concern still
exist regarding the potential dangers over the advantages of this approach. As long as the tissue is not
radioactively treated, or is only minimally treated, a safe and more reliable choice for revision ACL
restoration is the use of these allograft tendons which has a comparable failure rate to autografts and no
increased risk of infection. These situations wherein revision surgery is involved, using autografts further,
could result in increased morbidity at donor site with additional instability issues especially in cases where
new structures may need to be rebuilt, with evidence of autologous tendon degeneration. Allograft tissues
can be viewed as a good choice for this purpose, in light of the most recent evidence. A surgeon must choose
the most appropriate solution for problematic knee joint which is undergoing the revision ACL repair [3].
Following is a case study of 23year old recreational footballer who is returning to activities of daily living
after revision ACL surgery. This study has been presented as a Scientific paper and the Abstract is under
publication process at 3rd BRICSCESS Conference, MRIIRS, Delhi NCR, India.

PRESENTATION OF CASE
A male recreational footballer aged 23 years came to Sports OPD for post-surgical rehabilitation of left ACL
reconstruction. In the past, athlete already endured injuries to ACL twice on the left side which is the
ipsilateral side and once contralaterally as well. The first and foremost ACL tear took place when the athlete
was 18 years old and he underwent ACL reconstruction with lateral meniscus repair, wherein a same side
autograft from hamstring (gracilis and semitendinosus tendon) was taken. The player returned to sports after
6 months. A year later, this was followed by another injury to ACL ligament on the right side. The graft
used was similar to the previous surgery and another 6 months were required by the athlete to return to
sports. Third episode of injury occurred to the ACL ligament on left side (2 nd time on same side) and
happened when he was 21 years old. An arthroscopic ACL revision was performed using tibialis posterior
allograft + notchplasty + meniscectomyh(partial lateral), trimming and balancing + Medial Femoral Condyle
(MFC) bone marrow stimulation (BMS) + lateral extra articular tenodesis (LET) was done .

Magnetic resonance imaging displayed rupture of the graft of ACL, resulting in the typical anterior
translation of the tibial proximal part as compared to the distal portion of femur. It was a complex tear as it
involved the medial meniscus’s posterior horn including the posterior root attachment. Focal chondral defect
was seen in the adjacent inferior articular surface of the medial femoral condyle, on the posterior aspect. In
posteromedial corner of knee, a ruptured Bakers cyst was seen, with fluid tracking inferiorly in the medial
aspect of the proximal leg. The craniocaudal dimensions of the Bakers cyst were 4.2 cm.Thesuperficial
medial collateral ligament was seen to be intact.
Altered morphology and signal of the lateral meniscus is concerning for a re-tear rather than the
postoperative change. Focal chondral defect seen at the medial patellar facet. Structures of the posterolateral
corner including the intraarticular popliteus tendon, fibulae collateral ligament and tendon of biceps femoris
are intact. Iliotibial band is also intact. PCL is intact. Tendons of quadriceps and patella are normal. Rest of
the patellofemoral articulate cartilage is fairly well preserved.Large joint effusion is seen with fluid in the
patellofemoral recesses.

SURGICAL HISTORY
For surgery, patient was in supine position with a leg holder. Notchplasty was done for the noted narrow
femoral notch. Anterior cruciate graft tear was noted, tibial and femoral tunnels were prepared, previous
graft and sutures were then removed. ACL Reconstruction was done with tibialis posterior allograft (MTF).
Femoral tunnel of 10 mm was fixed with tightrope RT and tibial tunnel of 10 mm was fixed with Biosure
HA screw 11 x 35mm.
Lateral extra articular tenodesis was performed using central 1cm strip of ITB, passed beneath LCL and
fixed in the femur with healicoil PK 4.5 suture anchor and ITB tightening was then done. Complete
meniscal loss was observed in medial meniscus’s posterior horn. Bucket handle tear was spotted in posterior
horn extending to the body, in the 2/3 zone – the Avascular irreparable zone for which trimming and
balancing was done. Sutures of previous failed repair were also noted. MFC grade ¾ geographical chondral
wear was noted – BMS was done. Rest of the joint was normal.
Post Surgery, special instructions were given by surgeon including NWB x 1 week, PWB x 1 week, FWB x
1 week.
After this protocol, patient came to MGM Sports physiotherapy department for rehabilitation with the chief
complaints of pain on anterior aspect of knee, difficulty in knee bending and walking and performing
activities of daily living. Patient was assessed on 14/03/2023.
PRE-REHAB PHYSICAL EXAMINATION
Examination started with:
1.Pain testing
2.Range of Motion (ROM) assessment
3.Strength testing
4.Muscle girth evaluation

1 Pain Rating Difference between

affected and non-
affected extremities
NPRS 5
2 ROM Range in degrees
Right Left
Knee Flexion 125 30 95
Knee Extension 0 0 No difference
3. Strength Kg
Right Left
Knee Flexors 12 2 10
Knee Extensors 11.5 2 9.5
4. Muscle Girth Cm
Right Left
Above knee 3” 44 40 4
Above knee 6” 54 50 4
Above knee 9” 62 60 2
Below knee 6” 35 34.5 0.5
PROTOCOL

ACL Reconstructive Surgery with Allograft Rehabilitation Protocols (Weeks 4-8)

Electrotherapy
Week / Manual Aerobic
Exercise therapy
s Thermotherap therapy training
y
Static exercises for - quadriceps, hamstring,
Russian Current
glutes, back, and abdominals Dosage: 10-sec
Dosage: Ramp Patellar
hold,10 reps,2 sets
1 sec, on 4 sec mobilization
Off 9 sec Burst grade 2
SLR supine with brace locked in full
4 40, PPS for 10
Dosage: extension 2 sets 10 reps
minutes Scar (of
stitches)
Multiple angle isometrics at 30,60,90
Icing for about mobilization
degrees of knee flexion.
10 minutes.
Dosage:10 reps,2 sets,5-sec hold
Myofascial
release for
Multiple angle isometrics continued.
Quadriceps,
Heel slides pain-free range
Russian Current Hamstring
Dosage: 2 sets 10 reps
Dosage: Ramp and calf
Walking 1 min
1 sec, on 4 sec muscles
5 Prone hangs. Dosage: 5sec hold 10 reps (with hinge
Off 9 sec Burst, alternate
knee brace)
60 PPS for 10 days
Pelvis and trunk stabilization exercises grade
minutes Scar (of
1.
stitches)
Dosage: 2 sets of 10 repetitions.
mobilization
twice weekly
With continuation of previous weeks
exercises,
Mini squats- Initially up to 20-30 degrees
using body weight.
Dosage: 2 sets of 10 repetitions.
Myofascial
release for
VMO training on VMO board.
Quadriceps,
Dosage: 2 sets of 10 repetitions
Hamstring
and calf Walking 2
Ankle plantar flexion and dorsiflexion with
muscles minutes (with
6 purple theraband.
twice hinge knee
Dosage: 2 sets of 10 repetitions
weekly. brace)
Pelvis and trunk stabilization exercises grade
Scar (of
2.
stitches)
Dosage: 2 sets of 10 repetitions.
mobilization
twice weekly
 Mini squats-upto 30-45 degrees using body
weight.
VMO training on VMO board.
Dosage: 2 sets of 14 repetitions
SLRs in all four planes with locked knee
brace in extension.
Walking 2
Dosage: 2 sets 10 reps
minutes (with
Bridging. Dosage: 2 sets of 10 repetitions
hinge knee
7 brace)
Hamstring curls.
Stationary
Dosage: 2 sets of 10 repetitions
cycling 5 min
Pelvis and trunk stabilization exercises grade
3.
Dosage: 2 sets of 10 repetitions.

Squats-up to 60 degrees using body weight.

Dosage: 2 sets of 10 repetitions
SLRs in all four planes .
Dosage: 2 sets 10 reps
Walking 2
Resisted bridging with theraband.Supine
minutes (with
and prone.
hinge knee
Dosage:2 sets of 10 repetitions
brace)
Pelvis and trunk stabilization exercises grade
8 Stationary
4.
cycling 6
Dosage: 2 sets of 10 repetitions.
minutes with
minimal
Lunges 30 to 45 degrees (with hinge knee
resistance
brace) Dosage: 2 sets 10 reps
Calf raises. Dosage: 2 sets of 10 repetitions
(with hinge knee brace)
ACL Reconstructive Surgery with Allograft Rehabilitation Protocols (Weeks 9-12)
Week Aerobic
Strengthening Balance
s training
Lunges 30 to 45 degrees. Dosage: 2 sets 10
reps
Total body resistance squats upto 60
Walking 2
degrees. Dosage: 2 sets of 10 reps
minutes (with
Calf raises.Dosage: 2 sets of 10 repetitions
hinge knee
Total body resistance mini squatsupto 20-30 Double limb stance with eyes closed.
brace)Stationar
9 degrees with ankle plantarflexed. 2 sets of Dosage: 2 sets of 10 repsinitially for y cycling 6
10 reps 30 sec and progressed to 1 minute minutes with
Single limb bridging. Dosage: 2 sets of 10
minimal
repetitions
resistance
Pelvis and trunk stabilization exercises
grade 5. Dosage 2 sets of 10
repetitions.
Total body resistance squats upto 60 Single leg stance with eyes open
degrees. Dosage: 2 sets of 10 reps initially for 30 sec and progressed to Walking 2
Single limb bridging. Dosage: 2 sets of 16 1 min and then eyes closed minutes (with
repetitions progression similar to eyes open of 3 hinge knee
Resisted calfraises (with 5 to 15 kg
sets. brace)Stationar
10 Dumbbells in hand) with a hinge knee
y cycling 8
brace. Dosage: 2 sets of 10 reps
Perturbations: initially anticipated minutes with
Single limb bridging. Dosage: 2 sets of 16
then unanticipated and progressed to minimal
Pelvis and trunk stabilization exercises
low and high magnitude and speed resistance
grade 6. Dosage 2 sets of 10
repetitions. respectively.
Single leg stance with eyes open
Total body resistance squats upto 60
initially for 30 sec and progressed to
degrees. Dosage: 2 sets of 10 reps Walking for 1
Core Strengthening exercises: abdominal
1 min and then eyes closed
min Stationary
curls.Dosage: 2 sets of 10 reps progression similar to eyes open of 5
cycling 10
11 Single-leg mini squats up to 20-30 sets. minutes with
degreesdegrees. Dosage: 2 sets of 10 reps minimal
Resisted hip abduction and extension in Perturbations: initially anticipated resistance
standing. Dosage: 2 sets of 10 reps then unanticipated and progressed to
low speed.
Total body resistance squats upto 90
degrees. Dosage: 2 sets of 10 reps Single leg stance with eyes open
Single-leg mini squat up to 45-60 initially for 30 sec and progressed to
degrees. Dosage: 2 sets of 1 min and then eyes closed Walking for 3
10 reps progression similar to eyes open of 5 min Stationary
Resisted hip abduction and extension in sets. cycling for 10
12
standing. Dosage: 2 sets of 10 reps min with
Resisted lateral holds Dosage: 2 sets of Perturbations: initially anticipated moderate
10 reps then unanticipated and progressed to resistance
Alternating lunge holds 30-120 sec hold high magnitude and speed
2 to 4 sets respectively.
 ACL Reconstructive Surgery with Allograft Rehabilitation Protocols (Weeks 13-16)
Aerobic
Weeks Strengthening Balance Proprioceptive training
training
Single-leg mini squat up to 45-
One-legged stance with the
60 degrees. Initiate
knee flexed. Step out on
Dosage:2 sets.10 reps Standing on the walk
the other leg with the knee
BOSU ball eyes without
flexed and keep the balance
Total body resistance squats 30- open. brace for
for 5 seconds. 2 sets 10
120 sec hold. Dosage: 30 sec to 30 sec
reps
Dosage: 2-4 sets of 15 to 20reps 1 min. 3 sets
13
Stationary
One-legged stance with the
Resisted hip abduction and Standing on BOSU cycling for
hip and knee flexed. Step
extension in standing. Dosage:2 ball eyes closed. 12 min
out on the other leg with
sets of 16 reps Dosage: for 10 sec with
the hip and knee flexed and
to 1 min. 3 sets moderate
keep the balance for 5
Alternating lunge holds. resistance
seconds. 2 sets 10 reps.
Dosage:30-120 sec hold 6-8 sets
Single limb One-legged stance with the
standing on BOSU knee flexed. Step out on Initiate
ball with eyes the other leg with the knee walk
With previous weeks exercise,
open. flexed and keep the balance without
Single-leg mini squat up to 60-
Dosage: for 30 sec for 5 seconds. 2 sets 10 brace for 1
90 degrees.
to 1 min. 3 sets reps min
Dosage:2 sets 10 reps.
14 Alternating lunge holds.
Stationary
Single limb One-legged stance with the cycling for
Dosage:30-120 sec hold 8-10
standing on BOSU hip and knee flexed. Step 12 min
sets
ball with eyes out on the other leg with with
closed. Dosage: the hip and knee flexed and moderate
for 10 sec to 1 keep the balance for 5 resistance
min .3 sets seconds. 2 sets 10 reps
Single-leg mini squat up to 45- One-legged stance with the
Initiate
60 degrees. knee flexed. Step out on
Standing on the walk
Dosage:2 sets.10 reps the other leg with the knee
BOSU ball eyes without
flexed and keep the balance
open. brace for
Total body resistance squats 30- for 5 seconds. 2 sets 10
Dosage: 30 sec to 30 sec
120 sec hold. Dosage: 2 to 4 sets reps
1 min. 3 sets
15 of 15 to 20 reps
Stationary
One-legged stance with the
Standing on BOSU cycling for
Resisted hip abduction and hip and knee flexed. Step
ball eyes closed. 12 min
extension in standing. Dosage:2 out on the other leg with
Dosage: for 10 sec with
sets of 16 reps the hip and knee flexed and
to 1 min. 3 sets moderate
Alternating lunge holds. keep the balance for 5
resistance
Dosage:30-120 sec hold 6-8 sets seconds. 2 sets 10 reps
One-legged stance with the
Single limb
knee flexed. Step out on
standing on BOSU walk
the other leg with the knee
ball with eyes without
With previous weeks exercise, flexed and keep the balance
open. Dosage: for brace for 2
eccentric strengthening started. for 5 seconds. 2 sets 10
1 min. 5 sets min
Quadriceps targeting squats. reps
Stationary
16 Dosage:5reps 2sets
Single limb cycling for
One-legged stance with the
standing on BOSU 14 min
Nordic Hamstring Curls. hip and knee flexed. Step
ball with eyes with
Dosage:5reps 2sets out on the other leg with
closed. Dosage: moderate
the hip and knee flexed and
for 30sec to 1 resistance
keep the balance for 5
min .3 sets
seconds. 2 sets 10 reps.
 ACL Reconstructive Surgery with Allograft Rehabilitation Protocols(Weeks 17-20)
Proprioception
Weeks Strengthening Balance Aerobic Agility Plyometrics
Training
Advance
Proprioception
training
Squats on the
continue with
BOSU ball eyes
previous phase
open. Three
exercises
Dosage: 2 sets cone
10 reps drills.
Quadriceps One-legged walk
Dosage:
targeting squats. stance on the without
Double limb 5 reps 3
Dosage:2 sets.10 foam pad with brace for 3
stance on sets
reps the knee flexed min Kicking a
wobble board
and progressed Stationary ball.
17-18 eyes open. Ladder
on the BOSU cycling Dosage: 2
Dosage: 10 sec training-
Nordic ball. Maintain for 14 min sets 10 reps
to 1 min front
Hamstring Curls. balance for 30 with
and
Dosage:2 sets.10 seconds and moderate
Single limb lateral.
reps change stance resistance
stance on Dosage:
leg. Repeat twice
wobble board 2 reps 2
for both legs.
with eyes open. sets
Dosage:10 sec to
1 min

19 Unilateral pelvic Squats on the One-legged Walk for Three Sit to stand
bridging on an BOSU ball eyes stance on the 3-5 min. cone from a ball.
unstable surface closed. foam pad with Stationary drills. Dosage: 2
with the ball in Dosage: 2 sets the hip and knee cycling Dosage: sets 10 reps
hand. 10 reps flexed. Maintain for 16 min 5 reps 3
Dosage:2 sets.10 balance for 30 with sets Side-to-side
reps Double limb seconds and moderate shuffle
stance on change stance resistance Ladder Dosage: 2
Unilateral wall wobble board leg. Repeat twice training- sets 10 reps
slides. for 10 sec to 1 for both legs. front
Dosage:2 sets.10 min eyes and
reps closed.3 times Dribbling of lateral.
basketball in Dosage:
Single limb squat position 40 2 reps 2
Step up and step stance on dribbles.2 sets. sets
down with a wobble board
hinge knee brace with eyes open. Throwing and
on. Dosage: 10 sec catching of
Dosage:2 sets.10 to 30 sec,3-5 basketball on
reps times BOSU ball.
Dosage: 20
 catches.2 sets.
Unilateral pelvic
bridging on an
unstable surface Squats on the
with the ball in BOSU ball eyes
hand closed. Tandem walking
Ladder
Dosage:2 sets.10 Dosage: 16 reps initially and
training-
reps 2 sets progressed to
front
heel-to-toe Sit to stand
Walk for and
Unilateral wall Double limb tandem walking from a ball.
3-5 min. lateral.
slides. Dosage:2 stance on and then brisk Dosage: 2
Stationary Dosage:
sets.16reps wobble board tandem walking sets 10 reps
cycling 2 reps 2
20 Step up and step eyes closed. for 30 sec to 1
for 16 min sets
down with a Dosage:1 min Side-to-side
with A figure
hinge knee brace min .5-6 times shuffle
moderate of 8
on. High-speed step- Dosage: 2
resistance drills
Dosage:2 sets.16 Single limb up and step- sets 10 reps
dosage:
reps stance on down drills.
2reps .2s
Jogging in place wobble board Dosage: 2 sets
ets
with sport card- with eyes open. 10 reps
pulling from the Dosage:1
variable min .5-6 times
direction.
Dosage: 30 sec
 ACL Reconstructive Surgery with Allograft Rehabilitation Protocols(Weeks 21-24)
Week
Strengthening Balance Aerobic Agility Plyometrics
s

Ladder training-
Single limb stance
front and lateral
on wobble board
and back. Squat jumps.
with eyes open.
Dosage: 2 reps 2 Dosage: 2 sets
Dosage:1 min .5-6
sets 10 reps
times.
Continued with Brisk Walk for
Deep forward
previous weeks 3 min. A figure of 8 Bounding.
lunges.
strengthening Stationary drills. Dosage: 3 reps
Dosage: 10 to 20
21 exercises with cycling for 18 Dosage: 3 2 sets
reps 2 sets initially
increasing min with reps .2sets
without resistance
repetitions and moderate Four quadrants
progressed to
sets resistance Side shuffle and jump
resistance.
freeze drills Dosage: 6 reps
Dosage: 2 sets 2 sets
multidirectional
10 reps
lunges on a star
pattern on the floor.
Dosage: 2 sets of
one complete round
Single limb stance
on wobble board
Side shuffle and
with eyes close.
freeze drills
Dosage:1 min .6 -8 Squat jumps.
Dosage: 2 sets
times. Jogging and Dosage: 14
10 reps
Deep forward progressed to reps 2 sets
Jogging in place lunges. running 3-5
with sport card- Dosage: 10 to 20 min Bounding.
Ladder training-
pulling from the reps 2 sets initially Dosage: 5 reps
22-24 front and lateral
variable direction. without resistance Stationary 2 sets
and back
Dosage: 45 sec to progressed to cycling for 20
Dosage: 3 sets
1 min resistance. min with Four quadrants
10 reps
moderate jump
multidirectional resistance Dosage: 2 sets
Figure of 8 drill.
lunges on a star 10 reps
Dosage: 3 reps 3
pattern on the floor.
sets
Dosage: 2 sets of
one complete round
POST-REHAB PHYSICAL EXAMINATION

1 Pain Rating Difference

NPRS 0
2 ROM Range
Right Left
Knee Flexion 125 125
Knee Extension
3. Strength Kg
Right Left
Knee Flexors 13 13
Knee Extensors 13.5 13 0.5
4. Muscle Girth Cm
Rt Lt
Above knee 3” 44 44
Above knee 6” 54 54
Above knee 9” 62 62
Below knee 6” 35 35

RESULTS
 Pain on NPRS
6
5 5
4
3
2
1
0 0
PRE POST

Range of Motion
Range in Degrees

150 125 125 125

100
50 30
0
Right Left
PRE POST
 Muscle Girth
70
60 62
60 54
50
Muscle Girth (Cm)

50 44
40
40 34.5 35
30
20
10 4 4 2 0.5
0
3 6 9 6

Levels of Muscle Girth left leg (in Inches)

PRE POST Difference

Flexors
Muscle Strength Extensors
16
14 13 13 13.5
Muscle Strength (in Kgs)

12 11.5
12
10 9.5
10
8
6
4
2 2
2
0.5
0
Pre Post Pre Post

Right Left Diff

Fig 1-: Strength testing Fig 2: Strength testing
Fig 3: Russian Current Fig 4: Range of Motion Measurement

DISCUSSION

In order to reduce pain and inflammation and regain functional range of motion, a specialized rehabilitation
program is necessary for a successful ACL repair which will provide monumental help in smooth
participation in everyday activities and sports, and restore the previously comparable quality of life.

The results of this study depicted that Russian current combined with closed and open kinetic chain
strengthening exercises with progressive resistance exercise of lower limb and core muscles, endurance
training of muscles, balance , proprioception, agility and plyometric training was beneficial for improving
knee flexion range, the size of thigh and leg muscles, and strength of quadriceps and hamstring muscles and
overall functional capacity of the patient was improved.

Ucar, Mehmet Ali et al. conducted a study and concluded that CKC exercises are superior to OKC exercises
for mobilisation following ACL surgery, allowing for a speedier return to everyday activities and sports [4].
As reported by Buckthorpe et al., 2019, the quadriceps muscle force and PFJ stress are seen to be at its
highest point during OKC movements like knee extensions. On the other hand, the quadriceps muscle force
and PFJ stress are highest during CKC activities like lunges and the leg press, close to full flexion. This is
the proposed mechanism of effectiveness of CKC over OKC training [5].

Nadeem, Nimra et al. performed a randomised controlled trial with 36 patients, wherein each group was sub-
divided into three groups and treated for 6 weeks with conventional treatment using closed kinetic chain
exercises, conventional treatment using open kinetic chain exercises, and conventional treatment using RICE
therapy respectively. They came to the conclusion that the group with closed kinetic chain exercises showed
significant improvement and thus, these exercise are unquestionably superior to operations in terms of
improving quadriceps strength and functional status [6].
A review by Michael D. Ross et al., on closed and open kinetic chain exercise implementation after ACL
reconstruction brought forth the conclusion that following ACL reconstruction, both aforementioned
exercises in the review could safely be used in the initial stages of a rehabilitation programme for
specifically working quadriceps strength by usage of certain biomechanics of knee joint. Athletes should
refrain from using more extended knee postures for OKC quadriceps workouts and more flexed knee
positions for CKC activities. The authors also advised the patients to focus on practising OKC exercises that
will help patients achieve volitional quadriceps control in the early stages following ACL surgery. Patients
should advance to CKC exercises that can help with muscle recruitment and co-contractions that mimic
functional activity as their volitional quadriceps control gets better. Furthermore, ACL damage and
reconstructive surgery may have negatively impacted balance and neuromuscular control processes, which
can be restored with CKC exercises. However, it has been observed that the normal motions of knee joint,
that requires adequate recruitment and activation of quadriceps during CKC exercise, may get hampered by
the inevitable occurrence of reflex muscle atrophy of the quadriceps brought on by the effusion and
discomfort associated with ACL reconstructive surgery, allowing functional impairments and quadriceps
weakness to continue. Because OKC quadriceps exercises isolate weak quadriceps muscle, they should still
be a part of the rehabilitation programme following ACL repair, even though the focus may later move to
CKC activities [7].

Amr Almaz Abdel-aziem and colleagues concluded in their study that the application of Russian current
stimulation in addition to traditional physical therapy increased the quadriceps muscle peak torsion [8].

Our outcomes were in agreement with those of Maffiuletti et al. It was his study that discovered, short-term
electrostimulation increases maximal voluntary strength by almost 12% and this was accompanied by neural
adaptations (including increased muscle activation and the cross-educational effect) and muscular
adaptations in healthy individuals [9]. Similar findings were made by Vaz et al., who discovered that both
the low frequency current and russian current may raise the maximal extensor peak torque of the quadriceps
muscles [10].

Furthermore, Snyder- Mackler et al. examined the effects of electrical stimulation and voluntary exercises
on muscular strength following anterior cruciate ligament replacement. Exercise and stimulation groups
engaged in quadriceps and hamstring co-contraction, with a 15 second hold and then a 50 second rest. The
Russian current stimulation group's findings in terms of increased muscular strength were noticeably
superior to those of the exercise group [11].ThiagoYukio Fukuda et all conducted a study on 30 male
subjects whereeach participant received three currents: two low(50 Hz) frequency currents, one without an
intrapulse interval (FES), the other with an intrapulse interval of 100 s (VMS), and a medium frequency
(2500 Hz) Russian Current modulated in low frequency. The quadriceps' maximal voluntary isometric
torque (MVIT) was determined. While using the three different forms of NMES, the MEIT, pain level, and
the highest intensity attained were also recorded. They came to the conclusion that the maximal electrically
induced torque while using Russian Current, FES, and VMS was the same. However, compared to low
frequency currents, the Russian Current has a better subject tolerance to higher intensities and causes less
pain [12, 4].
ACL damage and reconstructive surgery negatively impacts balance and neuromuscular control processes,
so we restored with that with balance and proprioception training and further improvement was achieved by
agility and plyometric training.

CONCLUSION
Thus, we report a case study of an athlete who is a recreational footballer and underwent a revision
reconstruction of ACL of left knee with allograft, and after that underwent a 6 months of ACL rehabilitation
programme. In this patient, application of Russian current was effective for pain reduction and helped in
strengthening of the muscles initially with closed kinetic chain strengthening exercises combined with open
kinetic chain strengthening exercises, in further progression vigorous strengthening and endurance training
of lower limb and core muscles, balance and proprioception training with agility and plyometrics training
provided a patient very good recovery and improvement in overall functional capacity of the patient after 6
months of rehabilitation.

ADDITIONAL INFORMATION
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial relationships
at present or within the previous three years with any organizations that might have an interest in the
submitted work. Other relationships: All authors have declared that there are no other relationships or
activities that could appear to have influenced the submitted work.

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