Several factors are taken into consideration when recommending orthotics following anterior cruciate ligament reconstruction.

To brace or not to brace: that is the question physical therapists face. Sounds like a rhyming mantra for any physical therapist who must determine whether a patient’s knee requires bracing following anterior cruciate ligament reconstruction (ACLR). After practicing sports physical therapy for more than 14 years, I can attest to the concerns that both immediate postoperative bracing and functional sports bracing pose.

Back in the 1980s and ’90s, medicine tried to scientifically support and validate ACLR protocols, including bracing. For every research article published that proclaimed ACLR bracing effective and necessary, research also stated that bracing may not be all it was cracked up to be. Empirical (or, at least, anecdotal) findings suggest the literature may be one of the least considered criteria for ACLR bracing. If this is the case, then what really drives ACLR bracing?

The number one priority is to protect the ACL graft and return the patients to their desired levels of function. Whether the patient received an allograft (cadaver tissue) or autograft (patellar tendon or hamstring tendon), medical professionals and patients alike are most conscious of protecting the graft immediately after surgery, and thereafter. However, we should not forget that the only reason to have ACLR is to return to unrestricted sports and activity. To that end, rehabilitation takes into account such variables as the patient’s age, activities, return to sport, ability level, and the final overall performance of the affected leg. Each case requires a thorough review of the patient’s situation.

Returning to Sports

Restoring the patient’s confidence is usually the last piece of the ACLR puzzle. No matter what you suggest for a patient in rehabilitation, there still is nothing like taking the first hit, jump, or twist on the reconstructed knee during the heat of battle.

The best we can do is prepare the patient with sequential and progressive training drills and plyometrics that closely simulate the patient’s preferred sport. Patients require constant feedback regarding the stability of their leg in order to push them closer to the edge of maximum performance. Returning to sports before confidence is restored leads to unwanted compensations and most likely poor performances on the field or court.

Acclimating To the Brace

Acclimating to the brace begins by wearing it during the beginning stages of movement and agility training. Depending on the physician’s protocol, the patient’s ability, and the goals of physical therapy, this may occur in the third to sixth month postoperative.

Initially, patients often complain about the brace binding, slipping, or just being uncomfortable during early use—despite a proper fit. By wearing and participating in therapy with the brace on, patients gradually become less aware of it, while at the same time becoming more reliant on the brace. Until the patient is fully acclimated, continue to check the brace for proper fit. One of the biggest hurdles to ordering an ACLR functional brace (or convincing the patient a postoperative brace is no longer necessary) is the treating physician. Imagine being in private practice, treating a patient who is ready to return to sports 4 months after ACLR. It is important to communicate with the patient’s physician on why a brace is recommended. Some physicians may not want to brace immediately. It is advised the therapist avoid committing political suicide by stepping on a physician’s toes, by recommeding bracing without their knowledge. Communicating with the tending physician will also avoid a situation where the patient is upset is because their physician and therapist have conflicting opinions.

To avoid these situations, speak with the physician prior to advising the patient. If you want to avoid losing an ACLR referral source, only advise the patient after you have spoken with, and comply with, the physician’s protocol. If your rehabilitation protocols differ from those of the physician, there is still room for communication. For example, if a patient comes into your office non-weight bearing in a knee immobilizer 3 weeks after ACLR, do not panic. Just call the physician and see if you can get that brace off and begin weight bearing as soon as possible.

A 2000 survey by the American Association of Orthopaedic Surgeons asked physicians about their use of ACLR bracing. The survey estimates 130,000 ACLR operations were performed in the United States in 2000. The survey also found that over the last 5 years, immediate postoperative bracing has remained constant at 88% of the time, while during the same period, functional bracing has declined from 64% to 46% in 2000.¹

There are two determining factors for ACLR bracing: the stability of the knee (determined by the operative placement and tension of the graft, as well as the presence or absence of other structural deficits); and the overall ability of the involved lower extremity (strength, power, motion, etc). Only after considering all of these variables should a clinician advise a patient on bracing. However, it is a good idea to ask patients their input on what they expect from a brace. This is sometimes more important than a scientific conclusion.

Indeed, patients themselves are responsible for trends in bracing as well—not so much the postoperative brace, which is controlled by the physician and the therapist, but the functional brace. If they intend on returning to competition, athletes of all ability levels may request a functional ACLR brace.

Patients are requesting their own functional ACLR braces in the clinic, not the laboratory, and the bracing companies know it. That is one of the reasons functional ACLR braces come sport-specific and in a variety of colors and patterns.

Financial Considerations

Financial considerations are another indicator when determining whether patients will receive functional ACLR braces. The retail price for an off-the-shelf functional ACLR brace is between $580 and $775 (the wholesale price is $300), while a custom brace is priced between $850 and $1,100 (with a wholesale price of $500).¹

How do you find a suitable brace for a patient? Different brands have different strengths and weaknesses. Call manufacturers and compare features. Examine braces up close at trade shows. And, most of all, choose the brace that best fits the patient’s needs.

Reference

1. Weinbaum F. Research questionnaire. 67th annual meeting of the American Academy of Orthopaedic Surgeons; March 15-19, 2000; Orlando, Fla.

Stephen Clark, PT, DPT, MHS, OCS, MBA, is a board-certified orthopedic specialist and owner of Athletic Physical Therapy in Los Angeles. He has dedicated his career to treating Olympic, professional, and recreational athletes.