Early Open Kinetic Chain Hamstring Exercise After ACL Reconstruction: A Retrospective Safety and Efficacy Study

Background: Hamstring tendon autografts are frequently used for anterior cruciate ligament reconstruction (ACLR), but they are associated with persistent hamstring strength deficits and delayed functional recovery. Current rehabilitation guidelines often delay open kinetic chain (OKC) hamstring exercises due to safety concerns, despite the limited supporting evidence. This uncontrolled, underpowered, and exploratory study aimed to evaluate the safety and effectiveness of introducing OKC hamstring strengthening exercises as early as three weeks after ACLR. Methods: An exploratory retrospective observational study was conducted at a single physiotherapy center on 13 patients (aged 18-35) who underwent primary ACLR with semitendinosus-gracilis grafts. Participants followed a standardized rehabilitation program including isometric leg curls at 60° and 90° knee flexion and long-lever glute bridges twice weekly, starting from postoperative week 3. Safety was assessed through predefined "safety flags" (pain > 4/10, hematoma, clinical hamstring strain). Strength outcomes, including isometric knee flexion strength at 60° and 90°, limb symmetry index (LSI), and endurance tests, were assessed at 6 and 12 weeks. Results: All participants completed the program without major adverse events. Pain remained consistently low (median 2.5/10), with only one transient episode exceeding the threshold. No other complications were recorded. Isometric knee flexion strength significantly improved between week 6 and week 12 at both 60° (p = 0.018) and 90° (p = 0.003), with large effect sizes. LSI at 90° also increased significantly (p = 0.006), whereas improvements at 60° did not reach significance. Endurance testing showed functional gains as early as 6 weeks. Conclusions: The early introduction of OKC hamstring strengthening exercises three weeks after ACLR with hamstring autografts appears safe and promotes clinically meaningful improvements in strength and endurance. These findings, while from a small uncontrolled study, challenge conservative rehabilitation protocols and support the reconsideration of early hamstring loading. Given the retrospective, uncontrolled, and underpowered design, these findings are hypothesis-generating and not generalizable beyond young adults with hamstring autografts; larger randomized trials are required.