








































DISABLEMENT MODEL CASE STUDY 

 

46 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020 
 

Total Motion Release® for Restoring Normal Knee Function after ACL 
Reconstruction: A Case Study 
Diane L. Stankevitz, DAT, ATC, CSCS, EMT* & Lindsey Larkins, DAT, CSCS, PRT-C† 
* East Los Angeles College, Monterey Park, CA; † University of Idaho, Moscow, ID     
 

 
ABSTRACT 

The objective of this study was to illustrate the case of an 
intercollegiate soccer player who sustained a grade 3 
anterior cruciate ligament (ACL) injury and underwent 
surgical repair at 4 months. The patient engaged in her 
regular daily activity prior to the surgical procedure. One 
week prior to surgery the patient produced 140° of active 
knee flexion and -1° of active knee extension, and scored 
69.0 on the International Knee Documentation Committee 
Subjective Knee Evaluation (SKE). One day post-ACL 
reconstruction by semitendinosus autograft, the patient’s knee 
range of motion (ROM) was 40° of flexion and 20° of 
extension and reported a score of 21.8 on the SKE. The 
patient began rehabilitation immediately following surgery 
with the goal to increase ROM of the involved limb. A Total 
Motion Release® (TMR ®) rehabilitation protocol was 
implemented for the first four weeks in lieu of a traditional 
ACL reconstruction rehabilitation protocol. Three sessions 
were completed each week over a four-week period, for a 
total of 12 sessions. Rehabilitation sessions consisted of 15 
minutes of ice massage of the quadriceps with simultaneous 
quadriceps contraction/relaxation immediately followed by 
TMR ®. The patient ended each session with progressive 
exercise: 5 minutes of half rotations on the bike on day one, 
progressing to a 20 minute light jog on the treadmill by week 
four. Patient was re-assessed by the orthopedic surgeon at a 
one and six month post-operative follow-up appointments. 
Changes in flexion and extension ROM and SKE were 
assessed weekly prior to treatment to evaluate knee ROM. 
Four weeks following the TMR® protocol, knee range of 
motion was restored demonstrating the effectiveness of 
TMR®. 

Key Phrases 
Exercise, surgery, patient outcomes  
 
Correspondence 
Dr. Diane L, Stankevitz, 875 Perimeter Dr, Moscow, ID 
83843 
E-mail: stankedl@elac.edu   
 
Full Citation 
Stankevitz DL & Larkins L. Total motion release® for 
restoring normal knee function after acl reconstruction: a 
case study. Clin Pract Athl Train. 2020;3(6):46-54. 
https://doi.org/10.31622/2020/0003.3.7.       
 
Submitted: March 26, 2020 Accepted: June 29, 2020 

INTRODUCTION 

Recovery from anterior cruciate ligament (ACL) 

reconstruction is a time-consuming undertaking 
both for patient and clinician.1-14 In the past 
decade, researchers have studied and published 
rehabilitation protocols that vary in effectiveness 
and duration, with an average total timeline of 6-
9 months to return to pre-injury activity.1-8 In the 
first four weeks alone, patients can expect to 
spend anywhere from 30-150 minutes in a single 
rehabilitation session and complete several 
sessions per week.2,8,12,14  Furthermore, 
neuromuscular electrical stimulation 
devices,2,3,5,8,9,12,14 and continuous passive motion 
(CPM) machines are commonly used in addition to 
supervised rehabilitation sessions.1,2,6-8,14 The CPM 
machine is sometimes used for several hours each 
day immediately following surgery with the goal 
to restore range of motion (ROM) quickly and 
avoid the formation of unnecessary scar tissue in 
the joint.1-3,8,14  

Across the literature regarding ACL reconstruction 
rehabilitation protocols, patients achieved similar 
results by the fourth week after surgery. The 
patient should be capable of bilateral pain-free 
step-up progressions to 60°, stationary biking, 
swimming, and proprioception drills (e.g. balance 
boards).1,4-9,11,13-15 To accomplish this, patients 
begin rehabilitation with a two-week post-
operative phase that includes bracing and 
crutches, with the goal to reduce pain and 
swelling.1-8 During weeks two through four, 
rehabilitation goals are to progress the patient to 
achieve weight-bearing with a normal gait, 
appropriate patellar mobility, and knee flexion 
ROM of 0° to 130°.1-14 The most common 
rehabilitation exercises to achieve normal gait 
during the first four weeks begin with a straight 
leg raises and gait training.1-6,8-12,14,15  

mailto:stankedl@elac.edu
https://doi.org/10.31622/2020/0003.3.7


Total Motion Release® for Restoring Normal Knee Function after ACL Reconstruction: A Case Study 
 

 

47 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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With such a strong emphasis on restoring joint 
ROM and muscular strength, it is important that 
clinicians have appropriate, effective, and time 
efficient tools to accomplish rehabilitation goals. 
In addition to local modalities (e.g., mobilizations, 
CMP), clinicians can incorporate techniques that 
utilize the central nervous system to improve ROM 
and increase strength at the involved joint and 
throughout the body. Total Motion Release® 
(TMR®) is a treatment approach that utilizes 
contralateral movements to influence neural 
coupling and the nervous system’s interpretation 
of electrical signals to the injured body segment.16 
Referred to as cross education, this 
mechanotransduction is a means by which a 
movement force (e.g. stretching, resistance) 
applied to the muscle fiber can influence balance 
of the neuromusculoskeletal system, helping to re-
align imbalances in strength and ROM. 17-19   

TMR® attempts to sustain a dynamic center of 
gravity as part of a unified system by treating 
imbalances in the body.17,20 Patients with pain, 
deficiencies, or impairments in one area of the 
body can be influenced by movements performed 
elsewhere in the body. The technique incorporates 
the use of contralateral exercises to the 
unaffected side to promote therapeutic results in 
the affected side.17 Although TMR® research is still 
in its infancy, some researchers have provided 
insight into the positive effects of TMR® on 
shoulder pain, range of motion, and muscle re-
education, while reducing rehabilitation session 
duration.20-23 

This case study includes the outcomes of a 
rehabilitation protocol in which a patient was 
treated with TMR® following ACL reconstruction 
surgery to restore normal knee range of motion. 

PATIENT INFORMATION 

The patient was a 20-year old female 
intercollegiate soccer player who suffered an 
injury of her left (non-dominant) knee during a 
game via a non-contact mechanism attempting to 
decelerate to avoid a collision with an opponent. 
The patient was referred to an orthopedic 
surgeon for magnetic resonance imaging (MRI) 
which identified an isolated Grade III ACL sprain. 

The patient underwent a semitendinosus autograft 
surgical reconstruction approximately four months 
later. The four month delay was contributed to a 
combination of the patient’s schedule and 
insurance authorization. The patient did not 
implement a detailed pre-surgery rehabilitation 
protocol except for activities of daily living and 
general conditioning. The patient reported to the 
clinic one week prior to surgery to assess her 
function prior to surgery.  

Outcomes utilized to assess knee function were 
range of motion (ROM) with goniometer 1,3,5-8,9,11-

13 and the International Knee Documentation 
Committee Subjective Knee Evaluation (SKE).2,24,25 

Initial outcomes were assessed one week prior to 
surgery and were repeated one day post-surgery 
and weekly for four weeks. Outcomes were also 
assessed at the one month and the six month 
follow-up.  

Active flexion and extension ROM of the knee 
were measured using a standard goniometer 
(scale marked in 1° increments; model 12-1002; 
MeyerDCTM, Hudson, OH). The same clinician 
conducted flexion and extension measurements 
prior to the commencement of the rehabilitation 
session at the beginning of each week.13,26 The 
ROM measurement was performed as follows: 
 

• Flexion: The patient started in a supine 
position with full knee extension and the hip in 
neutral. The axis of the goniometer was 
placed on the lateral epicondyle of the femur. 
The proximal arm was placed at the midline 
of the femur aligned with the greater 
trochanter. The distal arm was placed at the 
midline of the fibula and aligned with the 
lateral malleolus and the fibular head. The 
patient then flexed the knee as far as possible 
while flexing the hip.1 

• Extension: The patient started in a supine 
position with full knee extension and the hip in 
neutral. A bolster was placed under the ankle. 
The axis of the goniometer was placed on the 
lateral epicondyle of the femur. The proximal 
arm was placed at the midline of the femur 



Total Motion Release® for Restoring Normal Knee Function after ACL Reconstruction: A Case Study 
 

 

48 
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aligned with the greater trochanter. The distal 
arm was placed at the midline of the fibula 
and aligned with the lateral malleolus and the 
fibular head.1 

The SKE is a patient-completed questionnaire 
designed to detect improvement or impairment of 
symptoms, function, and sports activities due to a 
variety of knee conditions (e.g. ACL injuries).2,24,25 
The SKE form is divided into three domains: 1) 
symptoms (i.e., pain, stiffness, swelling, 
locking/catching, and giving way); 2) sports and 
daily activities; and 3) current knee function and 
knee function prior to knee injury. These domains 
are comprised of 18 items (1 for current knee 
function, 1 for sport participation, 7 for symptoms, 
and 9 for daily activities). Responses vary for 
each item. Item 6 requires a yes or no response. 
Items 1, 4, 5, 7, 8, and 9 use 5-point Likert scales. 
Items 2, 3, and 10 use 11-point numerical rating 
scales by which the responses to each item are 
scored using 0 to indicate the lowest level of 
function or highest level of symptoms, and the 
highest number to indicate no symptoms and full 
function. Items 2 and 3 are related to pain and 
the responses are scored in reverse where 
“Constant” is assigned a score of 0, and “Never” 
is assigned a score of 10. The response to item 
10a is not included in the overall score as it relates 
to pre-injury function. The results are summed 
(excluding item 10a) and the score transformed to 
a scale ranging from 0 to 100 (Figure 1). Higher 
scores represent higher levels of function and 
lower levels of symptoms, with a score of 100 
interpreted as no limitations and no symptoms.24 

SKE Score = �
Sum of Items

Maximum Possible Score
�×100 

Figure 1. SKE Score Calculation 
 

INTERVENTION 

Total Motion Release® can be implemented using 
a set of standardized movements, or by testing 
and treating with any movement of choice. The 
standardized procedures of TMR® consist of 
repetitively recording a patient-rated numeric 
scale of dysfunction between zero (e.g., no pain, 

tightness, or impaired function) and 100 (e.g., 
extensive pain, tightness, or impaired function) 
during active movement through the TMR® 

screening which includes six primary exercises 
known as the Fab 6.17 The Fab 6 movements, 
developed by the TMR® originator Tom Dalonzo-
Baker, include arm raise, arm press, trunk twist, 
leg raise, sit to stand, and bent knee toe reach 
(Figure 2). 17 The patient performs each exercise 
bilaterally and assigns a score to each movement 
for each side. The motion with the greatest 
bilateral discrepancy as perceived by the patient 
is treated first. Treatment consists of sets of 
repetitions and/or end-range holds of the Fab 6 
movements performed to the good side. Scores 
are re-evaluated after every two to three sets, 
until a patient-reported score of 5 or below is 
achieved. The Fab 6 is then repeated and 
rescored, and the next most discrepant movement 
is treated until balance is achieved across all 
movements.21,23,27,28 Modifications of the Fab 6 or 
additional movements can be incorporated to 
accommodate a patient’s limitations or needs. 

During the first week, which included the 
inflammatory phase of healing, the patient was 
instructed to use crutches to assist with weight 
bearing as tolerated. The patient was permitted 
to ice for pain but did not engage in any other 
forms of treatment or pain medication for the first 
week. Intervention commenced one week after 
surgery and the patient began attending 
rehabilitation sessions three times per week, and 
did so for the next four weeks. The patient began 
each session with a 15-minute ice massage of the 
quadriceps to produce a hypoalgesic effect,29 
while simultaneously isometrically contracting then 
relaxing the quadriceps of the affected limb with 
the knee in full extension (Figure 3).  

Figure 2: Fab 6 evaluation movements.30 



Total Motion Release® for Restoring Normal Knee Function after ACL Reconstruction: A Case Study 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020  

 

Figure 3. Ice massage over the quadriceps of the 
affected leg while simultaneously contracting and 
relaxing for 15 minutes. 

Immediately following the ice massage, TMR® was 
used with straight leg raises (Figure 4). 
Progression was indicated when the patient’s 
score decreased to 25 or less. As the patient 
progressed, knee hyperextensions (Figure 5) and 
the Fab 6 “Sit to Stand” movement were 
incorporated (Figure 6). The patient completed 
the movements on the injured side reporting a 
score between 0 (i.e., no symptoms and full 
function) and 100 (i.e., very symptomatic and no 
function). Because the patient reported the injured 
limb to have lower function, she performed the 
TMR treatment exercises on the uninjured side. The 
treatments consisted of either 3 sets of 10 
repetitions and/or 5 holds for 30 seconds and 
were determined based on the ease to the 
patient. After each series, the patient completed 
the exercise on the injured side and reported a 
new score. During session one, the patient ended 
by performing self-paced half revolutions for 5 
minutes on a stationary bike enabling the knee to 
flex and extend to 90° (Table 1). The patient 
progressed appropriately and by the eighth 
session was capable of 20 minutes of full rotations 
on the stationary bike. She progressed from the 
bike to the treadmill and at the end of the four 
week time frame, the patient was jogging at a 5 
mph pace at a 0° incline for 10 minutes on the 
treadmill (Table 1). In addition to her treatment 
sessions, the patient was instructed to perform the 
entire treatment series of TMR® each day at home. 
 

OUTCOMES 

At the end of 12 TMR® sessions, the straight leg 
raise had improved from an initial patient-
reported score of 70 to a final score of 0. The 
knee hyperextensions and sit to stand had 
improve to a score of 5 from an initial score of 60 
and 80, respectively (Table 2). The patient 
achieved 99.0% of pre-surgery extension and 
96.4% of pre-surgery flexion. The patient had 
achieved 98.3% of their initial SKE score. At the 
one-month after the TMR® rehabilitation protocol, 
the patient’s knee flexion was at 100% (140°) 
and extension increased 1° (-2°) from pre-
surgical scores.  The SKE scores improved 36%  

Figure 4. The starting (left) and ending (right) positions for the 
straight leg raise 

Figure 5. The starting (left) and ending (right) positions for the 
leg extension. 

Figure 6. The starting (left) and ending (right) positions for the 
sit to stand. 



Total Motion Release® for Restoring Normal Knee Function after ACL Reconstruction: A Case Study 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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from the initial intake prior to surgery.  At the six 
month follow-up, knee flexion and knee extension 
were also measured at 140° and -2° respectively 
(Table 3). During week three, the patient reported 
an incident in which she was struck in the knee 
resulting in a minor regression. 

 

 

DISCUSSION 

The purpose of this study was to explore the 
effects of a rehabilitation protocol that included 
TMR® on knee range of motion after ACL 
reconstruction. Researchers have indicated an ACL 
reconstruction patient should achieve greater than 
110° of flexion and full knee extension by the  

Table 1. Comparison of TMR® to a Traditional Rehabilitation Protocol for 12 sessions over four weeks 
after surgery. 

Traditional TMR® 
Sessions Exercises Sessions Exercises 

1-3 Arm Ergometer for Cardiovascular 
Fitness† 1-12 15 minutes ice massage with quadriceps 

contractions 

1-3 Wall slides‡ 1-4 Straight Leg Raises for a maximum of 6 
series* 

1-3 Patellar mobilization 30 to 50 times 
per day 2-12 Knee Extensions for a maximum of 6 

series** 
1-3 Gait Training† 5-12 Sit to Stand for a maximum of 6 series* 

1-3 Bike for ROM† 1-2 5 minutes half revolutions on the 
stationary bike 

1-3 Quadriceps long-arc (90°-45°)‡ 3-11 20 minutes full revolutions on the 
stationary bike 

1-3 Straight Leg Raises‡ 12 10 minutes treadmill at 5mph at 0° 
incline 

1-3 Step-ups in pain-free range‡ 

 

1-3 Proprioceptive/balance training‡ 
4-6 Portal/incision mobilization as needed‡ 
4-6 StairMaster† 
4-6 Wall squats† 
4-6 Wall sits† 
4-6 Prone hangs‡ 
4-6 Patellar mobilization in flexion‡ 
4-6 Stationary Biking† 
7-12 Tibiofemoral mobilizations‡ 

7-12 Continue balance and proprioceptive 
activities‡ 

7-12 Increase intensity of stationary bike† 

7-12 May add treadmill walking and/or 
elliptical† 

7-12 Advance intensity of pool program as 
tolerated 

* Series: 3 sets of 10 repetitions on the unaffected side followed by one set of 10 repetitions on the 
affected side. 
** Series: 5 repetitions holding each for 30 seconds on the unaffected side followed by one repetition 
at a 30 second hold on the affected side. 
† 10 to 30 minutes 
‡ 3 sets of 10 repetitions (3 times per day) 
Adams, Biggs, Rosenberg, Saka, Shaw, Shelbourne, van Grinsven 



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Table 3. Patient's Knee Range of Motion and Subjective Progress  

Timeframe Flexion Extension SKE Score 
1 week pre-op 140° -1° 69.0 
1 day post-op 40° 20° 21.8 
1 week post-op 50° 22° 24.1 
2 week post-op 110° 13° 34.5 
3 week post-op 130° 10° 44.8 
4 week post-op 135° 0° 67.8 
1 month follow up 140° -2° 94.3 

6 month follow up 140°   -2° 96.6 

fourth week of rehabilitation following ACL 
reconstruction surgery. 2,4-7,9,13 In this case study, 
the patient achieved greater than 110° of flexion 
and full knee extension by the end of the four 
weeks of TMR®. One month following TMR® the 
patient added an additional 5° of flexion and -
2° of extension which was maintained at the six-
month follow-up (Table 3). 

A direct comparison of the time to completion for 
traditional rehabilitation elements and the 
protocol including TMR® is provided in Table 1. 
Rehabilitation exercises were included if they 
have been established in the literature and are 
widely used in patient practice for rehabilitation 

to increase ROM following ACL reconstruction.1,4-

7,9,15 The TMR® protocol for the patient in this study 
was an effective method as compared to 
traditional rehabilitation, but was less time-
consuming and required less exercises.1,4-7,9,15 

Traditional rehabilitation averaged over 90 
minutes per session three to five times per week 
for four weeks,1,4-7,9,15 and can include home 
exercises performed 3 times per day. In contrast, 
TMR® averaged less than 45 minutes per clinical 
session three times per week for four weeks, as 
well as daily at home, and generated the same 
patient outcomes as a traditional protocol.  

Table 2. Patient's TMR® Pre and Post Session Scores  

 Straight Leg Raises Knee Hyperextension Sit to Stand 

Week Session Pre Post Pre Post Pre Post 

1 
1 70 55 NA NA NA NA 
2 55 15 60 55 NA NA 
3 15 10 70 55 NA NA 

2 
4 10 0 40 25 NA NA 
5 NA NA 25 20 80 50 
6 NA NA 10 5 50 40 

3 
7* NA NA 50 45 35 30 
8 NA NA 45 40 45 30 
9 NA NA 30 20 15 10 

4 
10 NA NA 10 5 15 10 
11 NA NA 10 5 10 5 
12 NA NA 5 5 5 5 

* Patient experienced a minor hindrance when a person ran into her knee.   



Total Motion Release® for Restoring Normal Knee Function after ACL Reconstruction: A Case Study 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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Cryotherapy was incorporated for yielding 
therapeutic effects associated with the decrease 
of motor nerve conduction. The amount of the 
multiple action potential denotes the amount of 
nerve fibers that responds to an appropriate 
stimulus.29 Therefore, the diminution of this 
parameter after the cold application could infer 
an escalation in the activation threshold of some 
nerve fibers, as well as the blocking of the fibers 
more sensitive to cooling.29 

Although the results were successful, some 
limitations exist. Goniometric measurements were 
not blinded and could have decreased outcome 
validity.27 To determine the greatest effects of the 
protocol used in this case study, additional 
research is necessary using a larger number of 
participants randomized into TMR® and 
traditional rehabilitation groups. Future 
researchers should blind the individuals measuring 
outcomes to the group assignments.  

CLINICAL BOTTOM LINE 

Total Motion Release®17,20-23,28 was an effective 
treatment to restore knee ROM following ACL 
reconstruction surgery that took less time per 
treatment session than traditional ROM 
techniques.1,4-7,9,15 Ice massage while 
simultaneously contracting and relaxing the 
quadriceps may have contributed to stimulating 
the muscle fibers.30 The stationary bike also 
assisted with the patient’s ROM.1,4-7,9,15  TMR® can 
be a practical, less time-consuming alternative for 
clinicians attempting to improve a patient’s ROM 
after ACL reconstruction. 

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Total Motion Release® for Restoring Normal Knee Function after ACL Reconstruction: A Case Study 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020  

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 3 – Issue 3 – November 2020  

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