28 Wissenschaft und Forschung

Efficacy of Closed and Open Kinematic Chain Exercises

on Ankle Sprain Rehabilitation
Wirksamkeit von Übungen in geschlossenen und offenen kinematischen
Ketten zur Rehabilitation von Distorsionen der Knöchelregion

Authors S. J. Kachanathu1, A. R. Hafez2, A. M. Alenazi3, S. M. Hassan2, A. D. Algarni4, A. Albarrati1

1
Affiliations Rehabilitation Health Sciences, King Saud University, Riyadh, Saudi Arabia
2
Physiotherapy, Cairo University, Cairo, Egypt
3
Rehabilitation Health Sciences and Physical Therapy, Salman Bin Abdulaziz University, Alkharj, Saudi Arabia
4
Department of Orthopedics, King Saud University, Riyadh, Saudi Arabia

Key words Abstract Zusammenfassung

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●
▶ Rehabilitation
▼ ▼
●
▶ Therapie
Background: Ankle sprains often result in ankle Hintergrund: Knöchelverstauchungen führen
●
▶ Physiotherapie
instability, which is most likely caused by dam- oft zur Instabilität des Sprunggelenks, welche
age to passive structures and neuromuscular höchstwahrscheinlich durch Schäden an passiv-
Schlüsselwörter
●
▶ effectiveness impairment. Most ankle sprains are treated non- en Strukturen und durch neuromuskuläre Funk-
●
▶ exercise therapy surgically with a rehabilitation program. tionsstörungen verursacht werden. Die meisten
●
▶ physiotherapy Methods: A sample of 40 subacute grade II Verstauchungen werden nicht-operativ, sondern
late­ral ankle sprain with a mean age of 21.8 ± 2.9 mit einem Rehabilitationsprogramm behandelt.
years were participated in this study and divided Methoden: Eine Studiengruppe von 40 Patien­
them into 2 groups. The first group (n = 20) fol- ten mit einer subakuten lateralen Knöchelver-
lowed strengthening exercises in the form of stauchung (Grad II) mit einem mittleren Alter von
Open Kinematic Chain (OKC) whereas, the sec- 21,8 ± 2,9 Jahre nahm an dieser Studie teil. Diese 40
ond group (n = 20) undergone Closed Kinematic Patienten wurden in 2 Gruppen eingeteilt. Die er-
Chain (CKC) for dorsiflexors, planterflexors, ever- ste Gruppe (n = 20) führte Kräftigungsübungen in
tors, and invertors muscle groups. Both study offener kinematische Kette (OKC) durch, während
groups performed respective exercise program die zweite Gruppe (n = 20) mit geschlossener kine­
for 3 sessions per week for 6 weeks. Study out- matischer Ketten (CKC) an den Muskelgruppen
come measured by functional rating (ADLs) score der Dorsalflexoren, Plantarflexoren, Evertoren
system of the Japanese orthopedic association, und Invertoren beübte. Beide Studiengruppen
range of motion (ROM) of ankle dorsiflexion führten ein Trainingsprogramm bestehend aus
and planterflexion by universal goniometer and 3 Sitzungen pro Woche für insgesamt 6 Wochen
visual analogue scale (VAS) used to measure the durch. Das Studienergebnis wurde durch eine rein
pain severity. funktionelle Bewertung (ADLs), ein Punkte-Sys-
Results: There was a significant difference in tem des Japanischen Verbandes der Orthopäden,
received 29.04.2015 VAS, ROM and ADLs in both OKC and CKC groups durch das Messen des Bewegungsumfangs (ROM)
accepted 28.09.2015 (p > 0.05). However, between group compari- der Dorsalflexion und der Plantarflexion mit Hilfe
sons; there was a significant difference in ADLs eines universellen Goniometers und durch eine
Bibliography in the CKC group than in the OKC group (p > 0.05). visuelle Analogskala (VAS), die verwendet wird
DOI http://dx.doi.org/
Conclusion: This study observed that ankle um die Schmerzstärke zu messen, ermittelt.
10.1055/s-0035-1565047
Phys Med Rehab Kuror 2016;
sprain patient rehabilitation with both OKC and Ergebnisse: Es gab signifikante Unterschiede
26: 28–31 CKC exercises are effective, Although CKC exercise in den Ergebnissen von VAS, ROM und ADLs in
© Georg Thieme Verlag KG is may be a better choice than OKC exercise when der OKC- bzw. der CKC-Gruppe (p > 0,05). Insbe-
Stuttgart · New York we consider functional activities especially ADLs. sondere gab es einen deutlichen Unterschied bei
ISSN 0940-6689 ADLs zwischen der CKC-Gruppe und der OKC-
Gruppe (p > 0,05).
Correspondence Fazit: Im Rahmen dieser Studie konnte be­
Dr. S. J. Kachanathu, PhD
obachtet werden, dass die Behandlung von
Rehabilitation Health Sciences
King Saud University
Knöchelverstauchungen mit Hilfe von OKC- und
11433 Riyadh CKC-Übungen wirksam ist. Trotzdem ist festzu­
Saudi Arabia stellen, dass CKC-Übungen möglicherweise OKC-
johnsphysio@gmail.com Übungen vorzuziehen sind, wenn wir funktionelle
Aktivitäten, vor allem ADLs, betrachten.

Kachanathu SJ et al. Efficacy of Closed and … Phys Med Rehab Kuror 2016; 26: 28–31

Introduction
▼ the participants were listed at outpatient clinic at the university
Lateral ankle sprains are one of the most commonly reported
musculoskeletal injuries [1, 2]. About 65 % of all lateral ankle
sprains are isolated as anterior tibiofibular ligament (ATFL) inju-
ries, while 20 % are combined ATFL and calcaneofibular ligament
(CFL) injuries [3]. It is also reported that 85 % of all ankle injuries
are ankle sprains and 85 % of those are inversion sprains [4].
Moreover, about one ankle sprain occurring per 10 000 people
every day [5, 6].
The most common mechanism of injury for lateral ankle sprain
is resulting from an internal rotation and adduction of the plan-
tarflexed foot. The plantarflexion and inversion position of the
ankle and foot places an excessive load on the ATFL and subse-
quent damage to the lateral capsulo-ligamentous complex. With
the failure of ATFL, secondary restrain to inversion occurs by way
of the calcaneofibular and posterior talofibular ligaments, plac-
ing them at similar risk for injury. The anteromedial joint cap-
sule and the anterior fibers of the deltoid ligament may be sec-
ondarily injured due to excessive eversion of the ankle and foot
that may occur during recoil from maximal inversion. Ankle
sprains are assigned grades I to III, ordered from least severe to
most severe ligament damage [7].
Protection of the ankle by means of functional treatment is
needed to avoid stress to the scar tissue in the inflammatory
phase of tissue healing. In the subsequent phases, the prolifera-
tive phase and the maturation phase, the emphasis lay on the
alignment and strengthening of the newly formed collagen fib-
ers. Physical Therapists use this knowledge about tissue healing
to construct an exercise program [8].
Various protocols have been developed for rehabilitation in both
acute and recurrent ankle sprains, by emphasizing management
of pain, swelling, range of motion, strength training, and pro-
prioceptive training [5, 8–17]. Strength training exercises are
used to increase muscular development and improve neuromus-
cular control [10, 12–15, 18] and strength gain during the first
3–5 weeks of strength training are thought to be primarily due
to neural factors [18]. Strength training has also been reported
to influence motor-unit recruitment, selective activation of ago-
nist muscles and their motor units, and antagonist co-activation
[20]. However, whether the long-term effects of these influences
extend to muscle proprioception is uncertain [9].
Goals of treatment during the acute phase of ligament injury are
to minimize swelling and allow the patient to begin walking. The
acute phase of treatment should last 1–3 days follow the injury.
A combination of protection, relative rest, ice, compression, ele-
vation, and support is used. The treatment of second-degree
sprains is rest, ice, elevation, and compression dressing or com-
mercially available air stirrup splint. Stirrup splints may result in
better outcomes, consider initial cessation of weight bearing,
early range of motion exercises, and consider referral to physical
therapy for early range of motion exercise and wobble board
training after recovery to reduce the number of recurrent inju-
ries and to prevent functional instability [10, 11].
The aim of the current study is to compare between closed and
open chain exercise in the treatment of ankle sprain.
Materials and Methods
▼ grades; no restriction, mild restriction, moderate restriction and
A sample of forty subacute grade II lateral ankle sprain patients
(24 females and 16 males) age ranged from 18 to 25 years with a
Kachanathu SJ et al. Efficacy of Closed and … Phys Med Rehab Kuror 2016; 26: 28–31
Wissenschaft und Forschung 29
mean age of 21.8 ± 2.9 years were participated in this study. All
hospitals. All of them were suffering from pain, swelling, and
limitation of the ROM of ankle joint. The participants were ran-
domly divided into 2 groups. The first group (n = 20) with a mean
age of 21.4 ± 2.65 years, followed a program of strengthening ex-
ercises in the form of Open Kinematic Chain (OKC) whereas, the
second group (n = 20) with mean age 22.1 ± 3.21 years were un-
dergone Closed Kinematic Chain (CKC) for dorsiflexors, planter-
flexors, evertors, and invertors muscle groups. A stretching re-
gime was also followed by ankle support (elastic bandage) in
both groups prior to their respective intervention. OKC and CKC
groups performed the respective exercise program for 3 sessions
per week for 6 weeks. Study outcome measured using a rating
score system of the Japanese Orthopedic Association to measure
daily living activities, walking (ADLs), universal goniometer is
used to detect range of motion (ROM) of ankle dorsiflexion and
planterflexion [12], and visual analogue scale (VAS) used to
measure the pain severity [13]. All the study participants signed
an informed consent form, and were informed about the whole
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procedures before testing and training. To ensure equity and
ethical considerations, this study was approved by the Institu-
tional Review Board (IRB).
The OKC group was submitted to a physical therapy program
which was in the form of strengthening exercises of dorsiflexion
(i. e. from supine lying position and ask the patient to move the
foot towards the body with a moderate resistance). Strengthen-
ing exercises of planterflexion (i. e. from supine lying position
and ask the patient to move the foot away from the body with a
moderate resistance). Strengthening exercises of eversion (i. e.
from sitting position and ask the patient to rotate the foot out-
ward the body with a moderate resistance). Strengthening exer-
cises of inversion (i. e. from sitting position and ask the patient to
rotate the foot inward the body with a moderate resistance).
Whereas, the CKC group was submitted to a physical therapy
program which was in the form of strengthening exercises of
dorsiflexion and planterflexion (i. e. from standing position and
ask the patient to stand on toes and then back to stand on the
whole foot with a moderate resistance), and strengthening exer-
cises of eversion and inversion (i. e. from standing position and
ask the patient to stand on toes with inversion and then back to
stand on the whole foot with inversion, asking the patient to do
the same exercise with eversion, with a moderate resistance).
Each exercise was performed for 10 repetitions with 3 sets, 6 s
rest between each repetition, and 1 minute rest between the sets.
Pre and post stretching was performed with OKC and CKC re-
gimes for planterflexors (i. e. from long sitting with one hand fix-
ing the knee and the other hand stretches the planterflexors
muscles) for 5 repetitions, 30 s in the position of stretch, 30 s in
the position of relaxation by using of ankle support (elastic
bandage) in both groups. Both OKC and CKC regimes were con-
tinued for 6 weeks, 3 sessions per week and was supervised by
the same Physical Therapist.
All the participants were assessed for pre and post intervention
training outcomes by functional rating (ADLs) score system of
the Japanese orthopedic association, range of motion (ROM) of
ankle dorsiflexion and planterflexion by universal goniometer
and visual analogue scale (VAS) used to measure the pain sever-
ity. The functional rating score system of ADLs measured by 4
severe restriction. For ROM, participants were sitting on a bed
with extended of the injured lower limb, the fixed arm of the
30 Wissenschaft und Forschung

goniometer is placed in parallel to the tibia and the movable arm

Table 1 Pre-post comparison of VAS, ROMs and ADL, in OKC group.
in parallel to the foot, then the subjects were asked to dorsiflex
and planterflex and recorded the angle of dorsiflexion and plant- VAS ROM of DF ROM of PF ADL
erflexion and VAS measured for the pain is represented from (0) Pre Post Pre Post Pre Post Pre Post
grade to (10) grade. ‘0’ grade means no pain, ‘10’ grade means Min 6 2 7 12 18 27 2 2
unbearable pain, from 1 to 10 means graduation intensities of Max 8 4 12 17 33 39 3 3
pain. The subjects were asked to indicate the level of pain by plac- Mean 7.04 2.86 10.13 14.86 25.86 34.27 2.86 2.22
ing a dash at the appropriate level on the 10 cm horizontal line. SD 0.82 0.75 1.39 1.48 6.44 3.4 0.34 0.46
t-test 0.0007 0.009 0.007 0.035
* VAS = Visual Analogue Scale; DF = Dorsiflexion; PF = Planterflexion; ADL = Activities

Results of Daily Living

▼
Analyses were performed using SPSS 16.0 software for Windows Table 2 Pre-post comparison of VAS, ROMs and ADL, in CKC group.
(SPSS, Chicago, IL). The numerical values are presented as the
mean ± the SD of the mean, except when otherwise specified. VAS ROM of DF ROM of PF ADL
Paired t-test used to compare between pre and post in the group Pre Post Pre Post Pre Post Pre Post
and 2 sample unpaired t-test to compare between 2 groups Sig- Min 6 2 8 13 19 28 2 1
nificance was set at p ≤ 0.05. Max 9 4 12 17 32 40 3 2
The results of the OKC group showed a significant improvement Mean 7.18 2.86 10.27 15.13 26.04 34.81 2.86 1.31
of pain after physical therapy treatment from (7.04 ± 0.82) to SD 0.93 0.69 1.32 1.58 6.46 3.3 0.34 0.51

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t-test 0.0009 0.007 0.0008 0.025
(2.86 ± 0.75), ROM of dorsiflexion increased from (10.13 ± 1.39)
* VAS = Visual Analogue Scale; DF = Dorsiflexion; PF = Planterflexion; ADL = Activities
to (14.86 ± 1.48), ROM of planterflexion increased from
of Daily Living
(25.86 ± 6.44) to (34.27 ± 3.4) and ADL (walking) decreased from
(2.86 ± 0.34) to (2.22 ± 0.46), (●
▶ Table 1).

The results of the CKC group observed a significant improve- Table 3 Pre-post comparison of variables between OKC and CKC groups.
ment of pain after physical therapy treatment from (7.18 ± 0.93)
to (2.86 ± 0.69), ROM of dorsiflexion increased from (10.27 ± 1.32) VAS ROM of DF ROM of PF ADL
to (15.13 ± 1.58), ROM of planterflexion increased from Post 1 Post 2 Post 1 Post 2 Post 1 Post 2 Post 1 Post 2
(26.04 ± 6.46) to (34.81 ± 3.3) and ADL (walking) decreased from Min 2 2 12 13 27 28 2 1
(2.86 ± 0.34) to (1.31 ± 0.51), (●
▶ Table 2). Max 4 4 17 17 39 40 3 2
Comparison between both groups indicated no significant dif- Mean 2.86 2.86 14.86 15.13 34.27 34.81 2.22 1.31
ference between post measures of the OKC and CKC groups in SD 0.75 0.69 1.48 1.58 3.3 3.4 0.46 0.51
pain (p = 0.07), ROM of dorsiflexion (p = 0.06) and planterflexion t-test 0.07 0.06 0.06 0.03
* OKC = Open Kinematic Chain; CKC = Closed Kinematic Chain
(p = 0.06). However, there was a significant difference of ADL
(walking) (p = 0.03) in CKC group than OKC group (● ▶ Table 3).

combination of these) with progressive weight bearing and ex-

Discussion
▼ literature, both after an acute injury and in patients with Chronic
This study evaluated the effectiveness of 2 rehabilitation proto-
cols of ankle sprains which are open and closed kinematic chain
exercise (OKC and CKC) protocols and its effect on ADL. The results
of this study showed that, there was a significant result of the CKC
program for pain and ROM of dorsiflexion and planterflexion due
to using of exercise program in the form of strengthening exer-
cises, stretching exercises. Where all of the muscles around the
ankle joint are acting in the form of concentric and eccentric con-
traction at the same time and interacting with each other for giv-
ing high stability of the joint through strengthening of all muscles
around the ankle joint, and stretching which is gaining ROM.
Strength training protocols, including straight plane, diagonal,
and rotary exercises, may assist in full return to activity after
injury. Increases in strength can vary depending on the amount
of resistance and number of repetitions and sets. A 6 week
strength training protocol using rubber exercise tubing pro-
duced improvements in both strength and joint position sense
in the ankle. These findings suggest that strength training with-
out an emphasis on proprioception may be beneficial to improve
both strength and proprioception deficits [14].
The standard of care for grade I and II lateral ankle sprains is
functional rehabilitation, which consists of ankle stabilization
(via elastic bandage, bracing, taping, or external support or a
ercise. Concentric and eccentric strength deficits for the ankle
evertors, invertors, and plantar flexors have been reported in the
Ankle Instability (CIA), reinforcing the need to strengthen all
muscles around the ankle after injury [15].
Strengthening of muscles is improving ROM and function of dor-
siflexion, planterflexion, eversion, and inversion of the ankle
joint which is considered the walls of the ankle and must be
strong enough to protect the joint [16].
A stretching technique commonly is incorporated to restore full
ROM by targeting flexibility of the gastrocnemiussoleus muscle
complex. The stretching intervention may increase flexibility
before pain perception and allow the viscoelastic properties of
junctions between muscle and tendon to overcome the stretch
reflex or increase the stretch tolerance [17].
Improving ROM and function of the muscles and join state were
creating a controlling and balancing between agonist and ant­
agonist muscles of the ankle region and coordination of the
movements, i. e. improving active daily living specially walking
so, there was a significant difference in ADL (walking). The use of
an elastic bandage has fewer complications [18].
In the open chain group, improvement of pain was due to in-
creasing the power of the muscles which break down the pain
circle. Strengthening and stretching of the muscles is improving
ROM and function of dorsiflexion, planterflexion, eversion, and
inversion of the ankle joint.

Kachanathu SJ et al. Efficacy of Closed and … Phys Med Rehab Kuror 2016; 26: 28–31

The possible cause of CIA is dorsiflexor, planterflexor, and ever-
tor muscle weakness. Therefore, we emphasize strength training
in the rehabilitation program for ankle instability [24].
Early functional rehabilitation of the ankle should include range
of motion exercises and isotonic strength training exercises
[16, 19].
There are many treatment modalities for ankle rehabilitation.
These are reviewed, and the most effective training program for
rapid restoration of ankle movement, strength, endurance, and
proprioception must be selected [20].
In comparison, of results between both groups, there is no sig-
nificant improvement of pain, ROM of dorsiflexion, and ROM of
planterflexion but there is a significant improvement of ADL
(walking) only in the second group than in the first group, be-
cause the closed chain exercise was improving the function and
stability of the muscles and the joint more than the exercises.
The effect of mobilizations with movement at the talocrural
joint performed in the weight bearing position in individuals
with subacute and recurrent lateral ankle sprain was demons­
trated a positive effect on improving pain and dorsiflexion range
on weight bearing lunge measure than mobilizations-with
movement in non-weight bearing position[21–24].
Early post injury exercise can improve the healing and strength
of the damaged ligament by increasing collagen formation and
reducing adhesion, improved tissue nutrition, minimized mus-
cle wasting, and minimal loss of strength are also benefits of
early exercise [24, 25].
Our results are similar to other to randomized trails comparing
early mobilization and weight bearing that has shown patients
get back to work faster. The only difference in both groups was
improving the ADL (walking) in the closed chain group more
than in an open chain group. Both mobilization and strengthen-
ing exercise as a treatment of ankle sprains is giving excellent
mechanical stability of the ankle. From all of the above, it was
observed that closed chain is more beneficial in the treatment of
ankle sprains.
Conclusion
▼ 17 Terada M, Pietrosimone BG, Gribble PA. Therapeutic Interventions for
The present study concludes that closed chain is more beneficial
than open chain in treatment of ankle sprains in return to func-
tion. Although, both of them are effective in the treatment of
ankle sprain rehabilitation.
Acknowledgement
▼ mobilization in weight bearing and non-weight bearing in the treat-
The authors would like to extend their appreciation to the Dean-
ship of Research, Research Center, College of Applied Medical
Sciences at King Saud University for constructive scientific sup-
port during this research.
Conflict of Interest
▼ 24 Kumari N, Megha NA, Paresh P. Efficacy of weight bearing distal tibio­
There is no conflict of interest.
Kachanathu SJ et al. Efficacy of Closed and … Phys Med Rehab Kuror 2016; 26: 28–31
Wissenschaft und Forschung 31
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