To brace or not to brace, that is the question! In this week’s podcast we discuss some of the factors that we consider when bracing after ACL reconstruction surgery.
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#AskMikeReinold Episode 247: Bracing When Returning to Play After ACL Reconstruction
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Show Notes
- Return to Play Testing After ACL Reconstruction
- Neurocognitive Training for ACL Rehabilitation and Return to Play Testing
Transcript
Student:
All right, we got Lauren from Alabama and she says, “What is your opinion on putting adolescent athletes in a functional knee brace for return to sport following their rehab for an ACL reconstruction? Is it appropriate if they present with sound joint stability at the time of rehab discharge? Does your opinion change with return to contact versus non-contact sport?”
Mike Reinold:
Nice, good job, Lauren. Roll tide, war eagle. I think you nailed the sub-questions very well, by the way. And I think that was really good because those are usually the things that we start to talk about in these discussions is, is it a contact sport? What’s the status of their knee and stuff like that?
Mike Reinold:
So I think this is a great question. I think there’s still some variability throughout the country and maybe some surgeon preference or stuff, but I don’t know. Len, do you want to take this one from here and maybe start it off with, what do we know about the science of ACL bracing? How protective is it, and then based on that, what’s your experience and preference, I’d say?
Lenny Macrina:
Yeah, it seems like the science is not screaming. It’s as protective as we think, yet I think there is some form of protection, obviously with people wearing these braces. Because if you’re going to have a grade two or a grade three MCL, maybe it’s a grade one that you may get because you have that medial and lateral buttressing on the knee.
Mike Reinold:
Okay. I want to interrupt there real quick. I apologize, Len, but I think that was actually a very, very key point you just made right there. Sometimes it’s not the ACL we’re protecting too, sometimes it’s the status of other things in the knee. So that’s a very good point.
Lenny Macrina:
Yeah. I don’t think the brace protects against anterior translation of the tibia, which is how you’re going to tear the ACL. I think there’s an attempt to, but I don’t know if it’s truly going to do that. But with that, I’m still a proponent of it but that doesn’t mean I have to have all my adolescent athletes get one. It’s certainly going to be doctor preference. They have the final say with their patient that they sent to me for rehab.
Lenny Macrina:
But your question, the way you worded it is interesting that this person has tested out whatever test you’re doing, which again, be careful what test you’re doing, that’s a different podcast, to prove that they are ready to get back to the sport. So if they can test out, if you’re in Alabama and you work anywhere near the Andrews Group they’ll probably do a Biodex test, which tends to be a pretty good way of looking at quads to hamstrings.
Lenny Macrina:
And if they pass those tests and they mentally feel good about it, meaning they don’t have any fear of getting back, and they feel strong about getting back to their sport, running, cutting, jumping, contact, then maybe they don’t need that brace. But keep in mind, I am educating my kid and the parents that, because they’re young, they have probably a 25 or 30% higher risk of re-tearing either that knee or the other knee.
Lenny Macrina:
So I’m giving them all the information. I’m also giving them the cost of the brace and all that information. And then we make a sound decision based off of how they move, how they feel, mentally, physically. Give them a little background on the research. And then we make a sound decision together, especially if the doctor’s like, “Yeah, if you want it you can have it.” Sometimes doctors are wishy-washy, sometimes they’re not. I used to work in Alabama where everybody got a brace at that four to six month mark to begin the functional stuff.
Lenny Macrina:
I don’t know if I helped you any, but I’m not against it. I’m not against it. I think there’s some good research and some good information out there for the person to get back to the sport. It’ll help them potentially.
Mike Reinold:
Sometimes it turns into a “why not?” setting maybe. And I think Lenny actually added a couple of whys, like expenses and stuff like that. I’m not sure what your brace coverage may be for your insurance or whatever, but sometimes it’s a “why not?” Is it one of those situations where if you’re playing football and somebody completely takes you out again by your knee, is that going to magically protect your ACL reconstruction? No, you’re going to tear it again anyway, no matter what. But maybe it helps with some of the mild shifts and the pivots or the cuts or something like that. I think that’s what we’re trying to hope.
Mike Reinold:
Now, maybe this is sports specific too. What about contact versus non-contact? And some of the sports we deal with, Dave, I can’t imagine your girls or guys are using knee braces and getting back to gymnastics. That would be challenging, right? So what do you guys think?
Dave Tilley:
Yeah, it’s tough right now because they actually do have three, three recently in the last six months who’ve all got recommended braces and wear them and they complain a lot about whacking their other knee when they’re doing gymnastics and rubbing against it.
Mike Reinold:
Yeah, absolutely. And can you still compete at a high level with the restrictive nature of the brace, because it limits your range of motion and it’s a little bulky?
Dave Tilley:
Yeah. I think that what they do is similar to weightlifting. When somebody can’t straighten their elbow all the way, they show that before they compete so the judges won’t take off for it. A lot of gymnasts will do that. They show I can’t physically put my knees in the same kind of degree.
Dave Tilley:
But to Lenny’s point, unfortunately, there’s mixtures of both. I have some people who are wearing the brace and have re-tore recently, and it wasn’t super protective. Who knows whether that would have happened. I’ve had some wear it and swear by it. So, I think it’s in line with [inaudible 00:06:35], it’s a mixed bag here.
Mike Reinold:
Yeah. Anybody else have any experience with that a little bit? Dan, Lisa?
Lenny Macrina:
I will say, going off of your point of the brace rubbing your leg, I did recently put something on my Instagram page that showed a kid running on the treadmill with his brace on and without his brace on. And sorry, braces, but it was a lot worse with the brace. He physically was afraid to have the brace hit his other leg. So he would circumduct around which created this funky valgus force as he was trying to land versus running purely sagittal.
Lenny Macrina:
So this was relatively early in the process, like five, six months out of surgery, and he wasn’t a hundred percent. But it was like, “Oh man, that looks awful. That’s not what I expected. You looked better without the brace.” And the doctor gave him the brace. We had him run in it and I said, “All right, no brace. We’re going to get you out of the brace. We’re going to have you run on the treadmill,” which is just a treadmill running. And he looked a ton better without the brace. And I think everybody agreed on my social media pages.
Mike Reinold:
Nice. What else? Dan?
Dan Pope:
The only thing I was going to add, and this is [inaudible 00:07:39] ago is that sometimes I’ve had some athletes with a teared ACL, say with a hyperextension injury of the knee, and that’s not to say that they would hurt themselves in the future with the same exact mechanism. But my thought is, okay, this brace may help prevent that. If that’s the original mechanism, maybe that’s going to be more helpful, whereas it may not help against other sorts of mechanisms.
Dan Pope:
So that’s at least one of the thought processes that I use, when trying to decide whether or not we should use this brace, with parents or athletes when they’re trying to return back. Especially when they have a surgeon who is wishy-washy about whether or not they want to give the brace in the first place.
Mike Reinold:
Yeah, that makes sense. How about you, Lisa?
Lisa Russell:
Well, I haven’t worked with very many ACLs, but this is maybe a Lenny question, I guess. If I was trying to decide, I suppose, if someone was going to wear the brace, I’m just picturing somebody playing soccer. And I wouldn’t want to have as much contact with another player in the field that had a brace on their leg for my own safety. Athletes tell you, do they feel like they get a little bit of a bubble that people aren’t quite aggressive towards them? I don’t know.
Mike Reinold:
I’m going to jump in and say… I’m going to say the exact opposite. I think you’re a target. You’ve got a bullseye. If you’re trying to win and it’s life or death in these athletes’ minds, sometimes you got to target. A lot of people don’t want to show vulnerability with that, because now they’re going to… This is a terrible example, but just what popped in my head. If you’re a pitcher, a baseball pitcher and you’re wearing a knee brace I’m probably going to have my guy that bats 280 but is really fast, bunt. Sorry. You just showed your card and your card was you don’t have good agility probably, so I’m going to try to bunt and beat it out. So just as an example.
Lenny Macrina:
I would say on the flip side though, keep in mind many, many, many football team, offensive linemen and other positional players wear braces to play, not just immediately after an ACL, but as a preventative thing. Tom Brady still wears a brace under his pads on his left knee from his ACL that was probably more than a decade ago, as a protective thing. So you can get by.
Lenny Macrina:
My example of the kid running on the treadmill and he’s a 15 year old kid learning to run again after an ACL. These guys play at a very, very, very high level with these braces on bilaterally. Offensive linemen wear them on both knees as a protective thing. The University of Alabama still, many teams, I know Alabama does, put them on prophylactically on their linemen.
Lenny Macrina:
So I definitely think you can get away with it and do very well with it in sports. So I think it’s completely individualized as the person, how they feel, their insurance coverage, the kid’s mindset, the parents’ mindset with it, the doc and so many different variables. But something to definitely explore with your athlete as they’re trying to get back.
Mike Reinold:
All right. Final opinion. Contact sport, the doctor’s wishy-washy, has no preference. So if the doctor says yay or nay, then it is what it is, right? But the doctor says it’s up to you, whatever. And they come to us because they’re always going to, and say, “What do you think?” So I think first off, (a) what’s going to be our bullet statement? Is it that, “Well, the brace isn’t perfect. It’s not going to prevent all things. But it may provide a little protection so it may be worth it if you’re comfortable wearing it.” Is that the too vague? Would anybody say that a bit more-
Lenny Macrina:
I would say it’s appropriate and I would take it one step further in that it’s not just contact sports, because most of the ACLs that happen are non-contact cutting.
Mike Reinold:
You could say that, yeah.
Lenny Macrina:
So I would be more-
Mike Reinold:
Do you change your opinion if it’s contact versus non-contact? Or change your recommendation?
Lenny Macrina:
Well, I’d say more so if it’s a cutting sport, which is what sports are not cutting sports? I guess, rowing. True. But the big sports of what’s going to happen is going to be volleyball, soccer, football, baseball, lacrosse, where you’re going to tear your ACL. Where we see all our patients from is that.
Mike Reinold:
Right.
Lenny Macrina:
Yeah, those are contact and non-contact injury, but mainly two-thirds are non-contact injuries when you look at ACL tears in general.
Mike Reinold:
Yeah. So I would say I’m supportive of the concept of bracing. I think I would almost want to wear it until you tell me take this dang thing off. Because then that tells me you have full confidence in your limb, no, kinesiophobia. No, “I’m beginning to get hurt again.” It’s, “I feel great. This thing’s limiting me. Take the thing off.” I think that’s what I would say is, “Let’s wear it as you get acclimated back into the sport and then go for it.” Anybody differ on that or is that our final recommendation? Pretty solid? Yeah. Great. Awesome.
Mike Reinold:
All right. Well, great episode. Good question. I think that’s a good one that we often… I like questions like this because these are the opinion questions where your patient is going to come to you and ask your opinion on something. It’s not permission, but it’s your opinion.
Mike Reinold:
So I think it’s good to know a little bit. So we learned a little bit. The science isn’t overwhelming that these things are magical, but they probably help a little, I think that’s something. So keep that in mind as you form your opinion based on who you’re working with.
Mike Reinold:
So, great question. Again, head to mikereinold.com, click on that podcast link to keep asking away and we will keep answering. And please be sure to rate, review, subscribe on iTunes and Spotify, and we will see you on the next episode. Thanks.
