By Ziad Dahdul, DPT
To say that bracing after an anterior cruciate ligament (ACL) reconstruction is controversial is an understatement. You ask any physical therapist their opinion on the effectiveness of bracing and you’re likely to get dozens upon dozens of different answers. Our experiences with this injury will 100% guide our opinions as any sports physical therapist has seen this injury way too many times to count.
But what does the literature actually say? That’s what I set out to find out when asking two questions:
- Should the athlete be braced ealry on following ACL reconstruction?
- Should athletes be braced as they near return to sport (RTS)?
First, let’s look at bracing in the acute and sub-acute stages post surgery. Many studies examined the effects of bra cing on joint effusion and knee stability in the early stages of rehabilitation post ACLR. One study found that when bracing was randomized in patients during the first three weeks post-ACLR, there were no differences in joint effusion at the 3- or 12-month marks after surgery (1).
In regards to knee stability, another study showed that acute bracing is used in the initial week or two of recovery in order to protect the quadriceps inhibited knee from sudden flexion under weight bearing loads (2). This can provide both an external support in addition to peace of mind to the athlete knowing that they are supported during a vulnerable period of the rehab process.
Although these are just two examples, we haven’t seen enough research in support or against the use of bracing in the early stages of the rehab process to conclusively lean in one direction or the other. In the absence of conclusive evidence, this is where we lean on surgeon preference/outcomes, the clinician’s experience, and the confidence level of the athlete when making a decision like this.
Return to Sport
When taking a look at functional bracing on athletes upon return to sport, we find evidence both in favor of bracing and against its use; however, the majority of the research lean against its use long term. One study found that functional bracing does not protect the reconstructed ACL nor improve long-term patient outcomes when compared to non-braced participants. (2). Also, another systematic review showed that post operative bracing does not help with pain, function, rehabilitation, or stability. (3)
The two studies above are just the tip of the iceberg as the majority of studies I came across showed no clinically significant differences when bracing versus not. Many will argue that the use of bracing plays a large role in the athlete’s confidence in their reconstructed knee as they initially return to their respective sport. I do agree that knowing your athlete and their mental state goes a long way in the decision making process and should be a factor in the decision making process.
At the end of the day, clinical experience and research are two pillars of evidence based practice. We must use both as a means of guiding how we practice and how we help our athletes return to sport. While the literature is by no means conclusive in one direction or the other, we have to take into account the mental component as athletes near clearance to return to their respective sports. And that includes the confidence that wearing a brace affords certain athletes.
In the absence of conclusive, high level evidence (as is the case here), making decisions for that individual patient is crucial and must take into account the evidence, clinical experience, surgeon expertise, and patient preference. As clinicians, it is in our athlete’s best interest to do everything we can to help guide them through this arduous process so long as we don’t create dependency and give them a “crutch”. It’s a fine line, but it’s something that we grapple with in the clinic on a day to day basis.
Blog post written by Ziad Dahdul, PT, DPT, OCS, is the owner of Ignite Phyzio & Sports Performance, a concierge physical therapy practice in Southern California specializing in one-on-one care. Connect with him on Instagram (@ignitephyzio and @zeeadd)
- Lindstrom M, Wredmark T, Wretling ML, Henriksson M, Fellander-Tsai L. Post-operative bracing after ACL reconstruction has no effect on knee joint effusion. A prospective, randomized study. The Knee Journal. 2015;22(6):559-564.
- Smith SD, Laprade RF, Jansson KS, Arøen A, Wijdicks CA. Knee Surg Sports Traumatol Arthrosc. 2014 May; 22(5):1131-41
- Rodriguez EC. Knee bracing after anterior cruciate ligament reconstruction. Orthopedics. 2016;39(4);602-609.