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Can bracing be used instead of surgery following an ACL injury?

8th June 2018

For anyone interested in the sports or activities which help us to keep fit and healthy the potential for injury is always present. Injuries will very often involve the knee joint. This is because the knee is one of the largest and most complex joints in our body.

The knee is a hinged joint between the thigh bone (femur) with the shin bone (tibia) allowing the smooth and controlled movement of the two bones as we walk, run, jump and twist whilst bearing the full weight of the body.


There are four bands of tough fibrous connective tissue in the knee (ligaments) which support and strengthen the joint to prevent the knee from moving beyond it’s normal range of motion.

  • Anterior Cruciate Ligament (ACL)
  • Posterior Cruciate Ligament (PCL)
  • Medial Collateral Ligament (MCL)
  • Lateral Collateral Ligament (LCL)

The ACL is the most commonly injured ligament. It keeps the knee from moving too far forward.

The most common causes of ACL injury are:

  • Previous ACL injury
  • Playing sports which involve sudden stopping or changes in direction
  • Collision
  • Accidentally twisting the knee – landing from height
  • Losing muscle tone from inactivity or age

An ACL injury should be diagnosed during a consultation with a healthcare professional but may still need an MRI (Magnetic Resonance Imagery) scan to determine the full extent of the damage.

Immediately following any knee injury, it is advisable to follow the PRICE protocol (Protection, Rest, Ice, Compression, Elevation).

http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/acl-injury

Rehabilitation following an ACL tear or rupture can take six to nine months to return to full activity. The level of activity and damage will determine which course of treatment is recommended.

The symptoms that specifically point to ACL injury are:

  • Instability - (The knee feels wobbly, buckles, or gives out which potentially opens the way for further injury if the knee buckles or “gives way” which put the other mechanisms of the knee under stress)
  • Restricted Range of Motion
  • Swelling
  • Pain - outside and back of the knee.

Consulting a health professional for an early diagnosis is essential. Following ACL tears the risk of further damage to the injured knee increased by 1% for each month between the initial injury and surgery. It is important to remember that injuries to the ACL can also damage other structures within the knee and that delaying treatment may add to that damage, leading to problems in later life.

https://www.nhs.uk/conditions/knee-ligament-surgery/decision/

What are the options?

There are alternatives to surgery being developed such as Stem Cell Research which encourage the ligament to grow back itself rather than be replaced by a tendon taken from elsewhere in the body (patellar tendon or hamstring tendon). However, this approach is still very new, and more study is being undertaken to determine its effectiveness compared to traditional treatment options.

https://www.2xu.com/us/stem-cells-vs-knee-reconstruction.html

A technique called the BEAR procedure involves creating a sponge bridge or scaffold within the knee and encouraging the ligament to reattach naturally. Although the results have been very encouraging it is still an experimental procedure and has just begun human trials.

https://www.premax.co/au/blog/new-acl-surgery-that-could-change-the-game

Unfortunately, there is still much debate on how to obtain the best results with various combinations of treatment and rehabilitation being studied and advocated. Various studies have monitored the recovery of ACL patients to measure the extent of their recovery and reinjury.

The main options are:

Your doctor will evaluate the need for surgery based on the extent of the damage to the ACL, age and the extent to which it will affect the quality of life.

https://www.nhs.uk/conditions/knee-ligament-surgery/

The procedure is commonplace with 200,000 Americans undergoing ACL reconstruction every year. However, various studies offer insights on the suitability of surgery as the best strategy. https://www.webmd.com/pain-management/knee-pain/news/20100721/torn-acl-may-heal-without-surgery#1

Surgery vs non-surgical options

The clearest conclusions from this research seems to be that if surgery is undertaken or the knee can recover without reconstruction, strengthening the knee is the key factor in recovery. The debate considers the comparison of results between groups of patients who had surgery and those who went straight into a regime of physiotherapy. There seems to be little difference between the results in a number of these studies.

There is also debate on whether bracing helps with recovery and reduces the possibility of re-injury.

https://www.mdedge.com/jfponline/article/65485/preventive-care/does-knee-brace-decrease-recurrent-acl-injuries

The clinical evidence may be considered inconclusive. However, athletes returning to sport report an increase in confidence and performance from wearing a good functional ligament brace.

It is common practice before and after surgery for patients to wear a ligament brace to protect the movement of the knee, control the range of motion and support the ligaments.

The best ligament braces have polycentric hinges which match the natural movement of the knee. With a rigid frame these braces are used to prophylactically to protect the knee from unwanted forces during sports. They provide external support for the structure of the knee in the same way the ligaments do internally and so protect their function.

https://www.ctikneebraces.co.uk/guide-to-cti/do-i-need-one.html

Conclusions

  • Research indicates surgery is not always the best option in every case.
  • A program of physiotherapy is essential for the best outcome irrespective of the level of injury with or without surgery.
  • Inconclusive research would perhaps indicate that bracing is not a complete alternative to surgery or physiotherapy but can certainly supplement the chosen treatment to offer protection against reinjury.

It is clear in the event of an ACL injury reconstructed or not, the mechanism of the knee has been weakened and is susceptible to re-injury. Building up the strength of the knee’s other structures helps to compensate for this weakness and minimise instability.

Surgery is still considered the best treatment for ACL injuries especially for younger and more active individuals who wish to continue in sports and exercise. This should be supplemented with strengthening exercises to build up as much natural support as possible from the other ligaments and muscles. A knee brace would provide support and stability for a knee help to protect the other structures in the knee from damage.

The importance of the knee in terms of our ability to move means that whether injured or not we should make every effort to protect it. A brace cannot replace the function of a damaged or missing ligament but the support it offers can keep our knee functioning and allow us to continue to do the activities we enjoy without injury.

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