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A bracing thought: Would the author have avoided a second ACL tear if he hadn’t retired his brace to the back of the closet after rehab got him back on skis? PHOTOS COURTESY OF MICHAEL PATMAS, MD ❚ CONTINUED FROM PAGE 17 ground ball and pivoted on my left leg to throw out a runner at home. My knee buckled like a sapling in gale force winds. I wasn’t wearing my brace at the time, and I knew at that moment that a second ACL reconstruction was inescapable. Whatever fibers might have been left after the tear the previous winter were certainly gone now. But by then I had lost my window of opportunity to have surgery before the ensuing ski season. As if possessed by the voice of folly, I actually opted to ignore the injury yet again. I knew that during the previous season the brace served as a great “external ACL” to make up for my damaged internal one. So, after going back to the closet to retrieve the brace, I completed the entire season without the ligament. My skiing did suffer, though. I found myself up against a psychological barrier: I couldn’t “let it rip,” so to speak. The doctors admitted that I could, conceivably, ski on my bad knee longer without having surgery, but I would eventually develop accelerated degenerative arthritis, which might limit me even more than the injury itself. So, I made the decision to have surgery one more time at the end of the season. I’m only 52 . . . a kid; I’m not ready to stop playing. My second surgery was a breeze. The doctor told me that, amazingly, all that was left of the first graft were a few hairlike fronds. The graft hadn’t torn, it had completely dissolved. What was even more amazing was that my meniscus was totally intact and unharmed. For the past season and a half, I had truly been skiing without an ACL. Typically, in such a situation the other knee structures will suffer additional damage, but I had none, most likely because the brace prevented the bones and other ligaments from rubbing against one another. Using a piece of my own hamstring, the doctors created and attached an ACL graft. Hopeful that the new graft would survive, they gave me a good prognosis after the second surgery. I was walking without crutches within a week, and after two weeks I was back in the gym and have been working out everyday since. I took classes—step, powerflex, running, spinning, weight training—effectively conducting my own physical therapy. The specter of another ACL reconstruction got me thinking about what I could do to avoid having to go through this a third time. My brace had served me well during two seasons without an ACL. Maybe I should never have taken it off, despite what the “experts” said. If I had been wearing it that day on the mountain and later at the baseball camp, maybe this wouldn’t have happened again. I found myself wondering, Is there any evidence that bracing can prevent re-rupturing the ACL? If so, why did all the experts and literature advise against it? I stopped wearing the brace after the first injury because conventional wisdom said I would become dependent on it. As it turns out, dependency might have been a better alternative. Had I done some more research back then, I might have continued wearing the brace. What The Researchers Say y quest for more information didn’t M take long at all, and what I found was quite interesting. This is a very controversial area with deeply held opinions and conflicting studies. What follows is an overview of the current evidence on the role of functional bracing in protecting the ACL-reconstructed knee, with particular emphasis on the skier. Despite more than 20 years of research, the role of knee bracing remains the subject of intense debate. Some doctors believe the brace should be worn while skiing for about one year after ACL reconstructive surgery to allow the ligament CONTINUED ON PAGE 20 18 Ski Patrol Magazine | Winter 2005
The researchers fou ❚ CONTINUED FROM PAGE 18 graft to “mature.” The brace prevents excessive strain and allows the injured person to continue participating in sports. Others feel that the sooner a patient retires the brace the better, so the leg muscles surrounding the knee don’t weaken further from nonuse and then become dependent on the brace for strength. Eric Schlopy, a top American ski racer now back on the race scene after ACL reconstruction, put it this way when I asked his opinion. “I’m looking at the top 30 skiers out there . . . nearly all have had an ACL injury, and there’s not a brace among them. My leg muscles are my brace,” he says. Schlopy’s is the dominant view, and if you’ve ever seen a racer’s thighs, you’d understand where that confidence comes from. Competitive skiers strive to rehabilitate their injuries to full working order so they can count on their bodies to win races for them rather than depend on equipment that might jeopardize their form and technique. By bringing their leg muscles back to pre-injury strength, they hope to ensure their ACLs are protected without relying on support from braces, which can be restricting and cumbersome. However, regardless of whether or not a skier is a professional athlete, if he or she ruptured an ACL the first time while in good shape, he or she is certainly at the same or better risk of doing it again, even after rehabilitating completely. So what about the rest of us mere mortals who lack the benefit of worldclass racer training and giant sequoia-like thighs? Does bracing offer us any protection against first or subsequent injuries? Interestingly, I discovered that many college football players are wearing ACL braces prophylactically. More than 80 percent of linemen and 50 percent of linebackers in the Big Ten athletic conference wear braces during games and practice. Bracing reduced knee injuries from 3.4 to 1.4 per thousand athletic encounters (i.e., games, practices, scrimmages) among college football players, according to one large study. The popularity of prophylactic bracing in college football is rapidly growing as more players and coaches become convinced by declining rates of injury. But in the snowsports realm, skiers may be a few turns behind. In 1997, Dr. Peter Nemeth and colleagues from the University of Ottawa published a study involving six expert ski racers with ACL injuries for whom they measured leg muscle contraction patterns while the athletes were braced and unbraced. The researchers found a clear difference indicating that bracing increased knee stability both subjectively (how it felt to the athlete wearing the brace) and objectively (the measurable strain/pressure on the joint) as suggested by the pattern and timing of muscle contraction during skiing. The study shows that bracing increases knee stability, regardless of the state of the ACL. Perhaps the most interesting data comes from the work of Dr. Bruce ACL ACL strain (%) (%) 10 10 standing at 30° unbraced standing at 30° unbraced 5 standing at 30° braced standing at 30° braced 0 seated at 30° unbraced -5 seated at 30° unbraced -5 seated at 30° braced -10 seated at 30° braced -10 20 40 60 80 100 120 140 0 Anterior 20 load 40 applied 60 80 to tibia 100 (in 120 newtons) 140 Anterior load applied to tibia (in newtons) Beynnon, at the University of Vermont, who placed a strain measurement transducer directly into an ACL at surgery and tested the effect of the brace on the graft (fig.1). As was clearly shown, bracing substantially reduces strain on the ACL when loads are applied anteriorly (forward). This is the same type of strain that might cause a skier to rupture the ACL. While a brace won’t prevent a skier from falling or tweaking the knee, the research does suggest that it could share the knee’s burden and make those anteriorly directed loads less threatening. This is considered important during the rehabilitation phase after ACL reconstruction. When the new graft is placed in the knee the body reacts by breaking it down, making it vulnerable to re-injury and stretching. The graft actually weakens during the first six weeks after surgery and then begins to slowly strengthen. At the six-month mark, the graft returns to about 50 percent of its original strength. It continues to strengthen for one to two years, while it is “vascularized” and incorporated by the knee (fig. 2). If a brace can reduce strain on the reconstructed ACL, is it possible that it Figure 1 ACL Strain Produced by Anterior Tibial Loading (After Beynnon et al. 1995) Figure 2 ACL Graft After Surgery (After Blickenstaff et al. 1977) 100 100 80 80 60 60 40 40 20 20 0 12 15 18 21 24 27 30 33 36 0 Weeks 3 after 6 surgery 9 12 15 18 21 24 27 30 33 36 Weeks after surgery Graft strength (%) (%) 20 Ski Patrol Magazine | Winter 2005
Page 1 and 2: V O L U M E 2 1 N U M B E R 2 T H E
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