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Re: Brace after 6 months for 14 year old -- Female soccer player, genu valgum...

Posted By: Michael Frind
Date: Tuesday, 25 March 2008, at 4:03 p.m.

In Response To: Brace after 6 months for 14 year old (Chris Fleetwood)

Dear Chris,

Here are some comments and questions:

1. Indeed, some OSs include functional bracing in their ACL-reconstruction rehabilitation protocols, while others do not. Bracing provides great protection against sideways forcing and injurious hyperextension, but does not provide immunity to twisting-type injuries (because of the easily sheared soft tissues of the leg). The well-defined protective capabilities of bracing are helpful in knee-demanding activities, including team sports such as soccer. Ligamentization of an ACL graft takes more than just 6 months; it proceeds for several years after graft installation, albeit at the one-year mark the nascent ligament is significantly stronger than it was at 6 months. So, using bracing, especially for the first year after surgery, is appropriate. (I would advise using bracing for longer than that.) Of course, this assumes that the bracing is comfortable and non-hindering; I will delve into this shortly.

2. Which make/model of brace does your daughter have? (Given the price, I would expect it to be a genuinely custom fabricated carbon-fibre-composite brace.)

3. You noted that your teenage daughter underwent the ACL reconstruction on December 10/07. You noted that the functional brace she was given is uncomfortable. This raises the question of whether or not the brace fits properly. When did she receive the brace? The reason I ask is that the date of delivery determines when the free-refit period begins. Typical free-refit periods range from a few months to a year. If the brace fit is in question, you can go to the clinician/orthotist/representative who fitted it, other clinicians/orthotists/representatives, or take up contact with a technical representative (or customer-service representative) at the manufacturer (you can take pictures of the brace on the leg, and e-mail them to the person you speak with).

4. You noted that your daughter is "the opposite of bull-legged (I presume you mean bow-legged)". Therefore, she appears to be knock-kneed (also known as genu valgum). Being knock-kneed increases a person's likelihood of ACL injury or reinjury (more on this later). It also increases the likelihood of a brace's medial hinge rubbing against the other (contralateral) knee. Various types of hinge covers (or padded brace covers) can help in this regard. (Most modern braces already have low-profile hinges. It is possible to learn to walk/run with one's knees further apart, although this should be done with the goal of improving stance in order to prevent injury/reinjury, not to accommodate bracing. Walking with one's feet too far apart can result in an inefficient gait and other biomechanical problems, and so this is not something to pursue without consulting a physiotherapist or other person familiar with biomechanics.)

5. Female athletes are 2-8 times more likely to incur ACL tearing (or re-tearing) than males, and there are various reasons for this. These include muscle-related aspects, a wider pelvis (so, more inwards-angled knees to begin with, in addition to the genu valgum that your daughter has), a narrow intercondylar notch (widened as a standard part of ACL reconstruction), and various neuroproprioceptive and balance/co-ordination issues. Has your daughter received a specific knee-injury-prevention training program (such as Cincinnati Sportsmetrics)? The purpose of such training is to train the athlete to avoid knee-risky movements such as landing jumps with the knees angled inwards. Also part of such training is hamstring strengthening (since females tend to have proportionally weak hamstrings), jump-landing training (to learn to have the knees more flexed when landing, since females tend to land with too-straight knees), as well as improvement of propriocetion/balance and co-ordination. (More information on female-athlete ACL injury prevention can be found here in the Knee Library.) Knee-injury-prevention training also brings the benefit of improved athletic performance (e.g. higher jump height). Additionally, the fact that your daughter is knock-kneed makes ACL-injury-prevention training even more valuable.

6. As an addendum to point 4: Given the problems your daughter is having with the hinge-rubbing problem (in the context of genu valgum), it is possible that there is no brace that will be entirely comfortable. (Incidentally, single-upright-type braces, which do not have a hinged strut on the medial side, are biomechanically problematic and are really only viable for osteoarthritis use, where the goal is to force the knee sideways.) One solution might involve wearing a padded brace oversleeve in conjunction with some type of padded sleeve on the unaffected knee. This is something to discuss with someone familiar with fitting and troubleshooting of the chosen brace. Another possibility is to avoid knee-demanding sports until the one-year mark, and to focus instead on strength training and knee-injury-prevention training. These are aspects to discuss with the orthopedist and the physiotherapist.

Yours truly,
Michael Frind.
Knee Library http://factotem.org/library

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