Finding the Proper Brace

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January/February 2005

By Richard Lee

The ability to get an athlete back in the game as quickly as possible following anterior cruciate ligament surgery has long been a selling point for rehab providers hoping to get a leg up on their competitors. Basically, the practice that wins all the marbles in this contest for patient volume is the one that can restore ACL cases to function fastest.

As such, providers have been looking for every edge to help them do just that. One that is currently capturing renewed attention is the postoperative ACL knee brace.

Traditionally, the postoperative brace has been viewed as an apparatus to provide wound protection rather than a device to help physical therapists rebuild function during the 2 to 12 weeks following surgery. However, that thinking has been changing. Some therapists and trainers—and surgeons, as well—feel function should be the primary concern.

FIT TO BE TRIED
Of paramount importance to abetting the restoration of function is a brace that fits properly. Unfortunately, achieving a good fit is rarely easy.

“That’s our biggest challenge with bracing,” says Ankenman. “It’s difficult to get the brace to fit correctly over the dressings, which sometimes can be quite thick. But if the brace doesn’t snug up correctly, it can slide down the leg. When that happens, the patient won’t be able to walk normally. He’ll walk with a limp or some other type of compensating gait, which will introduce for us a new layer of problems.”

On the other hand, if a brace fits too tightly, it can interfere with function and cause rehab progress to bog down. Either way, an ill-fitting brace will, as Ankenman puts it, “undo whatever good you’re able to accomplish in the therapy sessions.” Ankenman says that if it were left to him to design the perfect postoperative brace, it would—for starters—be slimmer than previous models. “Because postop braces have been so bulky, they’ve tended to trap body heat,” he laments. “For the patient, that makes the brace uncomfortable to wear. The lack of comfort results in problems with compliance.”

Another historical deficiency of some types of knee braces is their inability to control all three forces affecting the knee. “They’ve been able to control only two of them,” says Ankenman. “They do a great job with medial-lateral force and front-to-back force, but they can’t control rotation very well. This is their Achilles heel.”

The good news is that knee-brace manufacturers have been working to eliminate these and other shortcomings. “The technology’s much improved,” says Ankenman. “The new lines coming out this year show good progress in getting out the bulk. They’re getting much closer to being where they should be with regard to thickness.”

Ankenman notes that braces now hitting the market also feature innovative condyle pads and hinge technologies that further allow for better fit. “The condyle is adjustable in and out,” he says. “The value of this capability is that it allows the fit of the brace to be altered as the wound heals and the swelling subsides. It’s just a fact of life that a brace will fit one way when the patient is fresh out of surgery and another way entirely 3 weeks later.”

Materials employed in brace construction are also improving, having gone from old-fashioned steel to space-age carbon-fiber composites. Even braces still fashioned from metal are increasingly made of lightweight, aircraft-grade aluminum, which also offers a certain amount of malleability so that the shape of the brace can be modified to fit more precisely.

PROPHYLACTIC BRACING
ACL knee bracing can, of course, be worn beyond the initial weeks following surgery. However, the brace used after that time cannot be the same type as that which was first issued to the patient. For longer term application, a brace must be of the functional variety. “A brace worn longer than the time it takes for the wounds of surgery to heal and for the knee to regain full strength is intended to be used as a means of preventing reinjury,” Ankenman advises.

Taking the concept a notch further, some therapists are eyeing braces as a prophylactic to keep athletes—and workers—from sustaining first-time injury of the knee. “Proponents of prophylactic use of functional bracing advocate wearing it only during times of activity that will place high demand on the knee—in essence, only when engaging in strenuous sport, such as running, skiing, and basketball,” says Ankenman, who leans toward preventive bracing. “The return-on-investment can be huge. It costs X amount of dollars to put the athlete or employee in that brace before he needs it, but in the long run it avoids the far greater costs of surgery and rehabilitation,” plus the indirect costs of lost productivity as a result of time away from work during recovery.

Not everyone agrees on the merits of prophylactic bracing. Some see the apparatus for that purpose as counterproductive, if not entirely useless. “The problem with braces worn prophylactically is that there’s no way to purge the buildup of sweat that results from a wearer going all out at his sport,” according to Scott James, PT, a sports medicine–trained staff therapist at Clinton Physical Therapy Center in Clinton, Tenn. “With a lot of sweat trapped between the knee and the brace, the brace is going to slide around. That interferes with athletic performance, which causes the typical wearer to take off the brace. At that point, the protection is gone. Yet, that’s the precise point when the proponents of prophylaxis say the protection is needed most.”

James reveals that his sports medicine clients do not receive a green light to return to their game until the injured knee is able to function at 100% as determined through isokinetic testing. However, once they reach 100% function, James finds no reason to put them in a brace.

“The only indication, in my thinking, to being in a functional brace 12 weeks out and beyond is if it’s a workers’ comp patient who is forced to return to a work environment when he’s not yet back up to 100% functionality and the tasks he’ll be required to engage in entail very vigorous activity,” he explains.

Another argument in favor of bracing past the immediate postoperative period is that the apparatus can give the wearer a sense of confidence to go about his daily routine free from worry about reinjury. Naturally, there is always the risk that a brace wearer could become overconfident and get into situations where the device is pushed beyond its ability to protect. Ankenman is ambivalent about that. “Someone who pushes the brace too far is more than likely going to do that because it’s the nature of his personality to play hard, rather than because he puts too much faith in the ability of the brace to protect him,” he says.

NOT ALWAYS NECESSARY?
The expense and hassles of bracing, coupled with the better results being gained from today’s more advanced ACL surgery techniques, prompt some therapists, like James, to eschew braces entirely.

“The goal of the brace is to mend anterior translation, stabilize the knee,” he says. “But if your muscles are strong, then you shouldn’t have that anyway. You shouldn’t be more susceptible to injury than prior to the tear.

“At the practice where I was trained, we merely kept the patient’s knee stitched or stapled until 9 days postop. Rarely would a wound tear open after that. In the one instance I can think of where that did happen, our in-house physician simply treated it with disinfectant and it closed on its own by day 14, postop.

“We were very advanced in rehabilitation. We began seeing these patients 2 days postop, and initiated quad strengthening at 5 days postop. They were off crutches by 3 weeks out, maximum. We liked getting in there with an early start to therapy because we found that we could get a better result if the edema could be controlled right off the bat, versus letting the patient go 2 to 3 weeks out [before starting therapy], which you would have to do if the patient was in a postop brace.”

That begs the question: are those who advocate bracing up to 12 weeks postoperative being overly cautious—and needlessly so?

“It depends on what the rehabilitation consists of,” says James. “As long as the surgery hasn’t involved a hamstring graft and if the patient is receiving very advanced rehabilitation, being seen 2 days postop and starting to work on hamstring strengthening 7 to 9 days postop, then, yes, a brace can be seen as overutilized by going to the full 12 weeks postop. Besides, most patients aren’t going to wear them that long anyway. You’re lucky if you can get them to stay in the brace 6 weeks postop.”

Still, the evidence is abundant in support of the notion that both postoperative and post-postoperative bracing works. “The research and published literature into braces support well the understanding that usage is helpful postoperatively,” Ankenman comments. “What success really comes down to is patient education so that the patients know how to put the brace on properly in the event they take it off at home for wound or brace maintenance, and therapist selection of the most appropriate product for the individual patient.”

Making these selections is sometimes confusing given the array of products offered in this category, he adds. “You have to know the products. More important, you have to be able to differentiate between truth and hype, because some of the claims made by manufacturers for their products aren’t always supported by science,” Ankenman insists.

Separating truth from hype thus requires diligence on the part of therapists. “Read the journals, that’s one way to get up to speed on whether there’s science behind the products,” Ankenman recommends. “And if you’re fortunate enough to have product sales reps you can trust, they’re another good source of information.

“But, when you get right down to it, the best way to sort it all out is by putting the brace on the patient and then observing how it works in actual everyday living. And, until you’ve seen it work on a cohort of patients, you really can’t be sure it’s a helpful technology.”

The evidence, however, strongly suggests that it will be.

Richard Lee is a contributing writer for Rehab Management.

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January/February 2005