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Re: Is brace really necessary? - Brace best if combined with prompt ACL recon...

Posted By: Michael Frind
Date: Thursday, 1 May 2008, at 2:43 p.m.

In Response To: is brace really necessary? (mitch)

Dear Mitch,

Your posting received many superb responses from numerous previous respondents. What I will do here is review some of the salient points, and then add my own comments.

Excellent previous responses came from many people, including respondents with the screen names "perhaps" (who noted that "no brace is a substitute for an ACL") and "Meowkitkat" (who wrote "remember that what you do now will be what you have to live with for the rest of your life"). Dr. Mark Sanders also noted that all sports authorities (at least, all the United States ones) would recommend that you have the ACL repaired before returning to soccer.

Larry pointed out what I also like to emphasize: that bracing protects well against sideways forcing and injurious hyperextension, but does not protect against twisting-type injuries (more on this later). He noted how repeated giving-way incidents of an unstable knee cause cumulative damage to menisci (meniscal tearing) and articular cartilage (via bone-bruising). These concerns are very real, even if you return to football for "just one season".

DonJoy Braceman also warned about the long-term effects of further damage to the knee. I note that although bracing can improve stability of an ACL-deficient knee, the problem is that because the soft tissues are easily sheared (and also because it is difficult for the brace to grip the skin tightly enough to prevent twisting), there are practical limits to how much twist-protection any brace can provide. (Only in very special cases can a brace reliably protect against twisting. One example is alpine skiing, where the brace can be connected to the ski boot in a twist-arresting fashion. For football and soccer, don't expect a brace to protect against twisting-type injuries.)

Indeed, the damage you can do even by just having the knee give out once can cause a lifetime of problems! Please remember that repairs of cartilage tears do not always work well. As previous respondent AggieCatcher noted, meniscal tears can be very problematic, especially if they are complex and repeated tearing occurs.

So, you want to avoid damaging these structures in the first place. And, the best way to do that is to not expose your ACL-deficient knee to situations which are likely to make it give out. That means completely avoiding football until the ACL has been reconstructed and thoroughly rehabilitated. (Only if you had a very minor partial tear, hence with no giving-way and no instability, would it be appropriate to consider returning to knee-demanding sports without ACL reconstruction. Your knee has been diagnosed with a fully torn ACL, and the knee has given out and thus the ACL is completely shot. My own case involves partial tearing that is minor enough that I have never had any instability. In my case, wearing bracing, along with physiotherapy and strength training, was sufficient to return to sports. But your case is very different: your knee is unstable, and there is no ACL functionality left. Returning to sports without having the ACL reconstructed would mean a lot of deterioration for your knee.)

Meniscal damage is not trivial. I noted that the menisci are essential for protecting the articular cartilage (the cartilage that covers the ends of the bones and enables the knee to move smoothly). The menisci literally serve as shock absorbers for the knee, and they also serve to distribute compressive and shear loadings over the vulnerable articular-cartilage surfaces. The menisci also contribute to overall stability of the knee. And, they help the synovial fluid lubricate all the sliding surfaces. Losing even a small part of the meniscus means greatly increased loadings on the articular-cartilage surfaces, which means a greater likelihood of osteoarthritis. (Articles on all this can be found in the Knee Library at factotem.org/library.) To summarize: you want to avoid playing football on an ACL-deficient knee, because that means severe (i.e. not repairable) meniscal damage is much more likely. That would be a very heavy long-term price (i.e. pain for your whole life) to pay for just playing out this one football season!

Please keep in mind that missing an ACL means a lot of your knee's functionality has been compromised. The ACL is important each time you pivot or change direction, but it is also important each time you accelerate or decelerate. And, in addition to controlling twisting (specifically inwards tibial rotation) at the knee, the ACL (in conjunction with the PCL and other structures) plays a role in controlling how far the knee extends. (Here we can see another reason why a brace would be helpful for your knee). The ACL also controls how far forwards the tibia can slide, which means that having no ACL results in erosion of the rearmost edges of your menisci. And, particularly in cases where the collateral ligaments have been damaged, the ACL helps protects against sideways giving-way too.

So, even though your ACL is gone right now, that doesn't mean you don't have to worry about the ACL. The concern is the damage that will occur (if the knee gives out, or even if it does not give out but continues to be sloppy because of the chronic ACLlessness) to the other structures that are now being pressed into service to compensate for the missing ACL (and that are deteriorating as a result of being forced to fulfill a role they were never intended to fulfill).

In brief, my recommendation for you is this: have the ACL reconstructed (ideally with a patellar-tendon autograft), allow sufficient time for rehabilitation (I would recommend 6 months, but in any case be certain to heed the surgeon's protocol), and then wear a brace during football for protection against the sideways forcing and injurious hyperextension (which tend to be contact-type injuries). This triple-barrelled approach (i.e. having the ACL reconstructed AND wearing a functional brace AND top-notch rehabilitation), provides your knee with protection against twisting as well as against contact-type injuries. So, you would get the best of everything!

Since you play football and soccer, and also given that your knee has been ACL-deficient for 6 months now (i.e. in posting 335508, one month ago, you noted you were 5 months post-ACL tear at that point), I would strongly recommend a genuinely custom-made carbon-fibre composite functional knee brace with a full-tibial-shell construction. These are available from several firms, but the two most widely available are Ossur (Innovation Sports/CTi; this the one I wear and am very pleased with) and Townsend Design. Only custom-made carbon-fibre bracing provides maximum strength at minimum weight.

A reconstructed ACL should last the lifetime of the person, but if the person goes back to making the same kinds of high-speed planting-and-twisting movements which caused the original ACL to fail in the first place, then re-tearing can be expected. Since many ACL tears occur through violent planting-and-twisting movements, it makes sense to learn to pivot in a knee-friendly fashion. This means learning to pivot on only the front portion of the foot, rather than planting the entire shoe sole.

Please remember that moving at high speed means a higher risk of injury (or re-injury). This is because kinetic energy (which is the major determinant of injury severity) increases with the square of speed. So, if you suddenly plant the entire shoe sole and twist the knee while running at 10 miles per hour, then the damage to your knee would be four times as bad as if you were moving at 5 miles per hour.

Also important is proprioception. This is essentially just the feedback from your knee joint to your brain's motor-control center. Because your ACL is torn, the nerve endings embedded in the ACL are gone. That means that your brain is missing information on what is going on inside the knee. And, that means your brain cannot make decisions with regards to muscle activation and timing as well as it did before. This makes you more prone to injury. (If you have the ACL reconstructed, then the nerve endings might regrow, although there are still a lot of questions as to how well they can reconnect. Wearing a brace is helpful here because the device stimulates nerve endings located just below your skin surface. This provides a type of surrogate proprioception, which should help your brain get more information with regards to what is happening at the knee. In theory, this could enable better motor-control decision-making. This is a topic where more research is needed. But one thing is certain: it is best to have the ACL reconstructed before returning to knee-demanding sports like football.)

If you leave your knee ACL-deficient and return to knee-demanding activities now, you will find that the "secondary restraints" (i.e. the ligaments and other tissues besides the ACL) will slowly loosen. This "sloppiness" in knee movement is a very serious concern, because it means increased wear-and-tear on the menisci and the articular cartilage. In fact, the concern is so serious that a knee which has been ACL-deficient for more than 3 months is considered "chronically ACL deficient", a category which increases the likelihood of failure of a future ACL reconstruction and which makes allograft (cadaver) ACL reconstruction (which takes longer to ligamentize) not recommended.

In other words, the longer you leave your knee without an ACL now, the looser the knee will be in general. And, that looseness means that, if you have the ACL reconstructed later (say, after the upcoming football season), then success of that graft will be less likely (albeit it would still be worthwhile to pursue reconstruction).

Remember, too, that if you tear an ACL graft, reconstructing it again (i.e. revision reconstructing it) becomes much more difficult. Each time more tunnels need to be drilled into the bone (to anchor a new ACL graft), the probability of failure increases. There is also the pain and grief of having to go through surgery a second time.

So, by leaving your knee without an ACL for long periods of time (where a "long period" is defined as anything longer than 3 months from the date of initial injury; as noted earlier, your knee is already at 6 months post-injury now), everything starts to fall apart. Your knee would incur more damage (i.e. premature osteoarthritis). And, the outcome later one (when you do have ACL reconstruction) would not be quite as good. The longer the knee is left without an ACL, the more things stretch out and loosen up! So, don't let the knee go any longer without an ACL!

To sum up: if you return to football now (with no ACL), you will certainly cause more damage to the knee (even if the knee does not actually give out). Wearing a functional brace would definitely help, as would learning to pivot in a knee-friendly fashion. Also important is building and maintaining strong leg muscles (train for both strength and endurance), as well as exercises geared towards building proprioception, balance, and co-ordination. But it would be best to have the ACL reconstructed and fully rehabilitated first. Remember that proper return-to-sports training can really only be done if the ACL has been reconstructed.

So, your best bet is to combine all three aspects: immediate ACL reconstruction (ideally via autografting), rehabilitation (physiotherapy, including sports-specific exercises during the latter stages of post-surgery rehabilitation and also including learning to pivot safely), and use of functional bracing (for football and other knee-demanding activities).

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

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