ACL Tear - Brace vs. Immediate Surgery

Pertinent Questions

• Can the athlete with a torn ACL complete the season using rehabilitative exercises and brace?
• Can this be done safely without further injury to his ACL-deficient knee?
• Are there other considerations for having a ACL reconstruction during the season versus during season break?
  

Can the athlete with a torn ACL complete the season using rehabilitative exercises and brace?

• Prospective study of 43 athletes with 44 acute ACL tears
• Knees included in the study had NO chronic ACL insufficiency, combined ligament instabilities, torn menisci, osteochondral fractures or degenerative arthritis
• These athletes ELECTED for conservative treatment
• 70% i.e. 30/43 (31 of 44 knees) completed the season wearing knee braces (Walter Shelton et al, Am J Sports Med 1996)

Can the athlete with a torn ACL complete the season using rehabilitative exercises and brace?

• A decision-making criteria is used to screen for returning patients to high-level physical activity with non-operative management of ACL tears
  After screening of 93 consecutive patients with acute ACL tears, 39/93 (42%) were classified as candidates and 54/93 (58%) classified as non-candidates for conservative treatment
• 28/39 rehabilitation candidates chose non-operative management and returned to pre-injury activity levels
  22/28 (79%) returned to pre-injury activity levels WITHOUT further episodes of instability or a reduction in functional status (Fitzgerald et al; Knee Surg, Sports Traumatol, Arthrosc 2000)
  

Can this be done safely without further injury to his ACL-deficient knee?

• In Dr Shelton’s prospective study of 43 athletes with 44 acute ACL tears:
• 70% i.e. 30/43 (31 of 44 knees) completed the season wearing knee brace
• Only 12 patients did not buckle in the brace
• 19/31 (61%) knees buckled in the brace
• 29/44 knees (66%) were reconstructed at average of 6.9 months after injury
• 9 medial meniscal tears
• 2 lateral meniscal tears
• 6 medial and lateral meniscal tears
• 1 major articular cartilage defect

 

• Why such poor results in Dr Shelton’s study?
• Athletes were NOT screened as to who will likely be candidates for rehabilitation and bracing
• Athletes ELECTED for conservative treatment in order to complete the season
• Adequacy of rehabilitation not assessed prior to resumption of play
• Not everyone is suitable for this treatment and the answer in to choose the right candidate for success!

 

• Need to exclude athletes with multiple structural damage associated with ACL tears as they are at high risk of further knee damage with continued participation in high-level activity
  Sources:
• Andersson AC; Int J Sports Med, 1993
• Engstrom B et al; Int Orthop, 1993
• Daniel DM et al; Am J Sports Med, 1994
• Shirakura K et al; Clin Orthop, 1995
  

To Brace or Not to Brace?

• A survey on management of ACL injury was mailed to 234 orthopedic surgeons randomly chosen from the Canadian Orthopedic Association
  Return rate was 72% and 56% were from academic centers
  Patients described in the survey protocol were routinely managed by 80% of these respondents
• For the competitive athlete with a complete ACL tear,
• 64% would recommend reconstruction
  33% would recommend bracing and rehabilitation
  Mirza F et al; Clin J Sport Med, 2000

Brace Works

• Basic Science evidence
  EMG and biomechanics of a dynamic knee brace for ACL deficiency
  Found that dynamic bracing prevents quadriceps inhibition in symptomatic patients by exerting a posteriorly directed force to the proximal tibia and compensates externally for absence of ACL
  Acierno SP et al; Orthopedics , 1995
  Clinical Study evidence
  The effect of functional bracing on subsequent injury in ACL deficient professional skiers was evaluated prospectively
  Significantly higher proportion of injuries occurred in non-braced skiers compared with braced skiers (p=0.005)
  Risk ratio for subsequent knee injury comparing non-braced with braced skiers was 6.4 (13% and 2% respectively)
  Kocher MS et al; The J of Knee Surgery, 2003

Brace May Improve Performance

• Braces can improve performances in ACL deficient patients
• One-leg hop tests improved by 50% with bracing
  Mishra et al; Clin Orthop, 1989
• Ran faster figure-of-eight running drills and cutting maneuvers with bracing
  Marans et al; Can J Surg, 1991
• Straight running times faster with bracing
  Cook et al; Am J Sports Med, 1989
  

ACL Functional Brace Use in Sports Wojtys EM et al  AJSM 1996

• In vivo study
  Assess the effect of 6 popular braces on anterior tibial translation, isokinetic performance and neuromuscular function in 5 chronically unstable ACL deficient knee
  Found:
  Braces can decrease anterior tibial translation between 28.8% and 39.1% without the stabilizing contractions of the hamstring, quadriceps and gastrocnemius muscles
  With lower extremity muscle activation and bracing, anterior tibial translation was decreased 69.8% and 84.9%
  Improvement in spinal level muscle reaction time was seen with brace use
  But braces consistently slowed hamstring muscle reaction times at the voluntary level
  

Brace Alone is Insufficient

• “The Effect of ACL Deficiency and Functional Bracing on Translation of the Tibia Relative to the Femur During Nonweightbearing and Weightbearing”
  Beynnon BD et al AJSM 2003
• Found:
  Bracing resulted in significant reduction of AP laxity values to a level within the limits of normal knee during nonweightbearing and weightbearing postures
  BUT, the anterior tibial translation was 3.5 times greater than the normal knee when the ACL deficient knee transitioned from nonweightbearing to weightbearing eg landing from a jump

ACL Deficient Knee

• Knee stability during walking following ACL injury is the result of
• Passive connective tissue tension
• Learned motor patterns
• Muscular responses to mechanical stimuli
  

Rehabilitation

• Do not just concentrate on the knee!
  The hip, foot, trunk and shoulders all contribute to knee stability and ACL function
• Gary Gray PT - concepts of the body as a link system
• Stresses rehabilitation in sagittal, frontal and transverse planes
• Strong hips and ankles ease the impact on the knee
• Exercises that potentially maximize the success for returning to sports after ACL injury include:
  3-D matrix hop
  3-D matrix lunge
  Single-leg balance squats etc
• Ability to handle position of risk
  

Conclusion

• Not all athletes with pre-season ACL ruptures can salvage the season with rehabilitation and bracing
• Those with associated meniscal, cartilage or other ligamentous injuries should not be allowed to continue playing without surgery
• Proper selection of potential athletes who may be able to play on with rehabilitation and brace using a screening criteria has been shown to work
• Close supervision by the surgeon, physical therapist and trainer is needed for the athlete to safely complete the season without further injury to the ACL deficient knee
• Each injured athlete is unique and the plan of management needs to be individualized
  

Case 1:Quadriceps Femoris and Hamstring Muscle Function in a Person with an Unstable Knee Maitland ME, et al  Phys Ther. 1999

• 34-year-old man with bilateral ACL injuries
  Underwent autograft reconstruction of left ACL
  8 months post-reconstruction, left knee was unstable despite bracing
  Gait analysis and tests to detect the presence of muscle inhibition were performed prior to and after 12 weeks of physical therapy
  Outcomes:
  Muscle inhibition decreased
  maximal isometric knee flexion and extension torques increased
  Gait analysis showed 50% decrease in maximum knee extensor moment and increase in walking speed
  Patient felt better and his knee gave way less often
  

ACL Reconstruction – Does it Prevent Knee Arthrosis?

• Traditional ACL reconstruction techniques which only addresses the anteromedial bundle does not reproduce normal knee kinematics
  Bransson S, et al AJSM 2002
  Yagi M, et al AJSM 2002
  Gabriel MT, et al J Orthop Res 2004

Please note that the information contained herein is for general medical information only.
If you have any specific medical condition or queries, please consult your medical doctor.

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