“Knee-Setting” 1914

This is a historical perspective (Origin Story) of the Quad-Set. This is one small section of a larger article that is available for CEU’s. The Full article is 14 pages and has 40+ minutes of accompanying videos and will leave you with a much deeper understanding of this not-so-simple exercise.

Enjoy!

Origin Story: Quad Sets

NOTE:  I love origin stories.  But, not just the typical fictional character origin.  I want to know where exercises/exercise equipment came from.  I want to know why they were created and/or how they were stumbled upon.  I am a firm believer that if we don’t understand our history, we are doomed to repeat it (but we can, and should, learn from it).  Because of that, I often spend months tracking down archived articles that are hidden in the dark corners of forgotten library stacks.  Usually, when this is successful, I’m left with a much better appreciation for some random exercise or piece of equipment.  When I run into a wall, or a dead-end that itself is usually pretty revealing.  Luckily, I am often able to lean on some very resourceful individuals that can reach into even deeper and darker recesses and allow me to find the “first”  documented mention of my query.

Where did the Quad Set (QS) come from?  For 25 years, I never asked that question.  As I followed the trail of the QS through the literature, what I found was quite interesting – in the modern world the QS hasn’t changed drastically from the original “Setting the Knee” exercise first formally described in 1927.  What has drifted significantly is the current intent and “silver bullet” expectation of this exercise…

The first mention of anything resembling the modern QS was in a 1914 lecture on Orthopedic Surgery given to the University of Liverpool by Dr. Robert Jones.   In his extensive description surrounding his thought process and surgical interventions for internal derangements of the knee, he describes the convalescent care that he expected of all of his patients.  It is important to remember that these were patients recovering from an open knee surgery in 1927 where the big concern was minimizing movement to keep dust out of the surgical field.  After surgery, his patients were expected to be under complete bedrest with the knee fully extended for 4-5 weeks.  While he promoted rubbing of the leg (keeping it fully extended), he did advocate for, and encourage his patients to practice “contracting the quadriceps without flexing the joint.”  Just for perspective, this article is describing healthcare BEFORE the beginning of The Great War (WW1).

In a Public Health Report published in 1927, there was a discussion on the care of Pediatric patients suffering from Infantile Paralysis.  In these children suffering deleterious muscle weakness that was rooted in localized myelitis of the spinal cord, weight bearing was considered very crippling (in the long term) due to the  compensations that the children would develop, so these children were placed under complete bed rest.  A series of exercises targeted at each region of the body was meticulously described so that the care provider (a parent) would be able to apply specific exercises to their child’s affect region(s).  The first exercise (in each list the first exercise is the entry point/easiest) for the “extensors of the lower leg on the thigh” was an exercise called “Setting the knee”.  The description goes: “The patient lies on his back and tightens the knee cap by contracting the quadriceps muscle, without moving the leg.”  This appears to be the first named and formal documentation of the exercise Dr. Jones mentioned in his 1914 speech.

W.E. Tucker proposed a scale of graduated exercises in his 1937 article that provided advice on how to care for athletic injuries of the knee joint.  He recommended starting with non-weight bearing activities, the first of which appears to be a rudimentary description of a quad set. “Twitching and contracting the quadriceps muscle for two minutes every hour while lying on a couch.”  This was the first of 6 progressive exercises which culminated the patient skipping (all 6 weren’t done on day 1).

In 1943, Specialists working at the Army Convalescent Depot described an exercise regime for injured soldiers that were deemed unfit for service due to knee injuries (interestingly, 60% of their patients were injured during Football activities.)  These patients were non-weight bearing.  Each patient, on their own time, was required to perform a “static quadriceps contraction” for at least 5 minutes out of every hour every day.  Once these patients were progressed to weight-bearing, this QS requirement was dropped in favor of weight-and-pulley exercises, loaded ruck marches, and running.  

In 1945, a very similar exercise regime is described by the Canadians as they provided care for their soldiers injured during the “rigors of initial army training.”  Their stated goal -for soldiers undergoing knee surgery- was to “obtain a painless, stable knee with intact ligaments, a full range of movement and a strong, fully developed quadriceps muscle.”  In all cases, they began a “Quadriceps-setting” drill 48 hours prior to surgery and they resumed this exercise 48 hours after surgery.  Their description was in line with the quadriceps contraction without any joint movement.  Interestingly, this is where we see the terminology change from “Knee-setting” to “Quadriceps-setting.”  

Fast forward to 1962.  A thesis submitted to the University of Colorado by George Lee McLarren was the first instance where the efficacy of the QS was ] and investigated objectively. “Several investigators have expressed doubt as to the efficacy of muscle-setting exercises, but as far as could be determined no quantitative study of this has ever been done.”  At the conclusion of his study, he stated: “ it seems possible that the conventional ‘Quad-setting’ exercises may not be effective in preventing atrophy disuse when the extremity is immobilized.”  Once again the OG term “knee-setting” has been shortened to “Quad-setting”.   

The 1970’s and 80’s were the heydays of research into describing what is happening during the quad sets.  EMG’s were repeatedly done in as many minutely variable ways as possible for researchers to publish a new article.  Cadavers, isolated legs (removed from bodies and attached to vices), animals, and living humans were used to thoroughly and meticulously describe everything that is occurring at/around the knee when the VMO contracts.  In the 1990’s the research advanced into outcome studies on post-op patients.  The majority showed favorable outcomes.  Very rarely did a researcher advocate anything that opposed the established position that QS were valuable, and led to positive outcomes.  The Quad-Set exercise has been included in presumably every textbook on rehab across multiple professions since the early 1960’s.  In some instances pictures and descriptions have been updated; in others, not so much.  To say that he QS has been thoroughly investigated is an understatement.  And after all of that extensive research, we are left with questions that target the efficacy of this exercise, just like George Lee McLarren stated in his 1962 thesis.  

One question that I was unable to find any research on was what happens to the brain during a QS?  Why, with all the advanced imaging and data collection ability that currently exists, has some reacher NOT put a subject into a fMRI tube and asked them to “ tighten the knee cap by contracting the quadriceps muscle, without moving the leg”?

My interpretation of this origin of research into the QS is as follows.  Again, this is my interpretation on the totality of the research I have studied:

1. The original quad set was employed following open-surgical procedures to stabilize the knee while the patient was under bed rest or when the patient was suffering a condition that required full bed rest.   In every case, QS were the exercise of choice only when the individual was non-weight bearing.  Once that status changed, the “knee-setting” exercises were replaced with more appropriate exercises.
2. The intent of the QS was to prevent atrophy that was known to accompany the required bed-rest.
3. Each description that was provided in the research included some mention, description or expectation of “full extension” of the knee.
4. Non-trained individuals were expected to carry this out and/or QS were to be done on the individuals own time.
5. Those that detailed the exercise program included no sets/reps.  It was described as an expected time under tension  and was performed multiple times thought the day.  
6. The first detailed study on the effectiveness of a QS (1962) revealed less than optimal results in just preventing atrophy…. 

When the current use of the QS is compared against the original intent of the exercise 9and application of the exercise, it is clear that somewhere along the quad sets 107-year journey some drift has occurred.  A quick Google search brought me to a webpage of a social media influencer that has an article they wrote stating:  “The quad set is paramount to re-gaining quadriceps activation.”  They correctly explain/discuss how quad inhibition following injury/surgery is due to a neural inhibition, but then explain how using “the all-mighty quad set” exercise fixes this inhibitory reflex.  While research does in fact show that exercise is important to addressing AMI, a deeper reading of the research also describes how removing the cause (the inhibitory triggers: swelling, inflammation) of the AMI is actually more effective.  Their description of their version of the QS is as follows:

Lay on the ground or table and place a rolled up towel/shirt under your knee. This will act as a lever which will make it easier to activate your quadriceps muscle. 

1. Attempt to squeeze your quadriceps muscle using these cues:
2. Really focus on squeezing your quad
3. Sometimes touching the muscle, massaging it, or hitting it can help
4. Think about moving your kneecap up and into your hip socket
5. Push your knee down into the towel roll
6. Lift your heel off the table
7. Move your shin bone in the shape of a “J” by moving your knee down and your heel up at the same time
8. Squeeze both quadriceps at the same time 

I’m hesitant to be critical, however, their article perfectly highlights how our current application of the QS exceeds the capability of this very basic drill.  Their description (using a roll under the knee) changes the exercise from a quad set (no joint movement) to some variation of a Short-Arc exercise.  They then double-down on the importance of this atrophy preventing exercise with this statement:

“this program is for anyone looking to truly pre-hab their knee before surgery OR work on regaining their knee extension after a surgery or injury. It’s appropriate for anyone regardless of current fitness level and will build you from the ground up to tolerate the end ranges of knee extension.”

How devolved have humans become when an exercise originating ~1914 for convalescing, bed-ridden patients to prevent atrophy becomes highly recommended to anyone regardless of current fitness level to build muscle in 2022?  I’m not going to cite or name this website.  My intent isn’t to devalue what anyone is doing, my intent is to point out how the basic understanding of multiple professions (Athletic Trainers, Physical Therapists, Physicians, Chiropractors, Strength and Conditioning Coaches) have drifted in a direction that might not be beneficial.  I used this website as an example because it perfectly illustrates our combined inability to recognize the disconnect between knowledge and practice – their article is well written though and has a ton of likes/shares… We know (and they clearly state) that an inability to activate the quad after injury/surgery is due to an inhibitory reflex, yet we (and they) continue to try ad fix it with an exercise that was originally targeted at non-weightbearing individuals to prevent atrophy.  How did we get here?

I see this as an opportunity/challenge to move in a better direction.

Enjoy!

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