What Do Patients Say?

The majority of my former ACL patients were prescribed custom braces. However, half of the patients admitted they would likely have opted for the less expensive, off-the-counter versions if their insurance had not covered the cost of the brace. Most used the braces only for risky athletic activities (basketball, soccer, beach volleyball) after the first postoperative year. Their expectations of the braces were not symptom-relief of improved athletic performance, but prevention of further injury. Those who were 2 or more years postop had stopped using their braces for activities other than skiing, because they felt they no longer needed the extra support.

This again raises the question of whether the brace is actually providing added stability or just the added confidence to transition back to sports. Even if the latter is true, our objective in sports rehabilitation is to return our patients to a level of activity that is as close as possible to their pre-injury status. Some patients are hesitant to return to athletic activities out of sheer anxiety - and an athlete can't be effective on the court or field if he is more focused on protecting his knee than on what is going on around him.

In these cases, a functional brace may provide, if nothing else, the psychological crutch to return to athletic participation with confidence and skill. Furthermore, while some patients do feel a brace restricts their performance, they are often willing to make this comprise to prevent another injury. After all, ACL injuries can be debilitating, and the ensuing surgery and rehabilitation are major commitments of time and energy. Who would want to go through this process more than once?

What Do Physicians Say?

Do physicians prescribe functional braces for all their ACL patients? Most likely not. None of my referral sources prescribes braces as a matter of general protocol. They reserve functional braces for graft protection in ACL-reconstructed patients who wish to return to a high level activity (skiing, football, soccer), particularly within the first postoperative year until the bone-to-bone insertion of the graft has been fully incorporated. Additionally, they suggest functional braces for those who develop postoperative laxity, or for ACL-deficient patients who decide against surgical reconstruction. Physicians felt that custom braces were preferable due to a better fit, but acknowledged that patients often opt for an off-the-shelf brace if not covered by their insurance policy.

Choosing a Brace

As a patient progresses through ACL rehabilitation, who makes the decision about whether a functional brace is appropriate? Often, patients are the first to bring up the brace issue. They may assume that functional braces are part of the rehabilitation protocol, or they may be anxious to return to their sport and assume that a brace will help. This is our time to tell patients that while a brace may help prevent further injury, and may allow a more speedy return to athletics, it is not a substitute for adequate healing time or thorough rehabilitative strengthening.

At this point, patients should be referred back to their surgeon to discuss whether a brace is indicated. Every surgeon has a different opinion and protocol about braces, and it is important not to overstep our bounds as PTs by recommending (or discouraging) a brace without first getting the physician's input.

Once the decision is made to obtain a brace, an orthotist or other representative from the brace manufacturer can help choose according to the patient's needs. PTs can act as important intermediaries between the patient, physician, and orthotist, communicating such information as the patient's clinical status (any remaining instabilities or concomitant injuries) and potential activity level.

Brace measurements are usually taken several months after surgery when changes in thigh and calf girth (due to edema and atrophy) have resolved. While both custom and off-the-shelf derotation braces are designed to restrict hyperextension and internal/external rotation of the knee joint, custom braces are fit to the exact contours of the patient's limb. The more-exact fit of a custom brace may increase comfort and lessen interference with physical activity. For less active patients, a prefabricated brace may be adequate.

For more athletic patients, a closer fit may be more crucial, since the restrictive leverage of the brace depends on it contact with the limb. Custom braces may be cost-prohibitive ($1000 or more) without adequate insurance coverage. Off-the-shelf braces are considerably less expensive (approximately $500). There are also high-performance braces, engineered for more aggressive athletic use. These are made of sturdier materials, but may result in a heavier brace.

The Bottom Line

While there is clearly much controversy surrounding the true efficacy of functional braces, the fact remains that they are often included in ACL rehabilitation, and many active patients consider bracing a necessity in their successful return to athletic participation. When a patient receives a brace, however, the final piece of the rehab puzzle is making it clear that the brace is not a cure-all.

Even with a brace, some precautions will always be necessary to protect a reconstructed knee. The brace is no substitute for thorough, progressive rehabilitation and maintenance exercise.

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Tracy Akins, MPT, OCS, CSCS, practices at Athletic Physical Therapy, a private practice in West Los Angeles, Calif. She can be reached via email: tracy@athleticpt.com
References

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