RETURN TO ACTIVITY FUNCTIONAL BRACING

Two high quality (McDevitt 2004, Birmingham 2008), but limited studies showed no significant differences between braced and unbraced individuals returning to full activity following isolated primary ACL reconstruction. The studies follow a multitude of clinical, patient-reported, and injury outcomes after ACL reconstruction. One study included patients with bone-patellar tendon-bone autografts, the other study included patients with hamstring autografts. While both are high quality and concordant, the studies are limited by several factors. First, the studies utilized braces that may be inferior in fit and quality to custom braces available today. Second, the studies were relatively short term: 12 months for McDevitt and 24 months for Birmingham (but with compliance only measured for 12 months). The studies vary in terms of timing and duration of the bracing protocol, do not involve large cohorts and may be underpowered for some outcomes. Hence, current evidence, though limited, does not demonstrate any benefit from bracing during the process of returning to sport after ACL reconstruction.

Benefits/Harms of Implementation

There are no proven benefits to functional bracing following primary ACL reconstruction. While there are no significant harms, there is increased cost and early bracing has been linked to decreased thigh circumference.

Outcome Importance

The two high quality studies included a wide range of clinical, injury, and patient-reported outcomes, many of high significance. The studies are not large cohorts and may be underpowered for some outcomes. 

Cost Effectiveness/Resource Utilization

Functional bracing increases the cost of ACL recovery by approximately $200 - $2,000, depending on choice of brace. Current evidence does not establish a benefit from the additional cost.

Acceptability

The use of functional bracing during return to activity/sport after ACL reconstruction is variable. This recommendation should be acceptable to the sports medicine community.

Feasibility

Highly feasible for surgeons not to require a brace for return to activity and sport progression after isolated ACL reconstruction.

Future Research

While there is no evidence to date of clinical benefit from brace use for return to activity following isolated ACL reconstruction, the variance in bracing protocols and relatively small size of the study cohorts suggests more research is warranted. Opportunities for further study include analysis of newer custom designed braces, the impact of graft choice on bracing efficacy, outcomes of long term bracing after return to sport, and the potential role of bracing in subgroups such as high risk young athletes as well as following treatment of combined injuries such as multi-ligament reconstructions or ACL reconstruction and meniscal repair.