Episode 235 | The Bracing Illusion: Why Your Knee Isn’t as Straight as You Think

What is up team? And welcome back to another episode on the ACL Athlete Podcast. Today, we’re talking about bracing—especially after post-op ACL. My general take is that some surgeons are way too conservative with their protocols and need to update them. This is just something that I’ve really noticed. We’ve been pretty fortunate to work with people from different countries, from different states here in the U.S. And just consult and be able to help these ACLers through different parts of the process. 

One thing that I noticed is that there is such a wide variety of protocols or beliefs around post-op bracing, bracing in general, in the ACL space. I’ll do another episode on this in more detail, in terms of the post-op brace and some of the assumptions there, using the post-op brace and what the research says, as well as functional bracing or return-to-sport bracing, which I will also do a future episode on. 

But today, I want to talk more about the bracing illusion that I see oftentimes. I’m speaking more specifically to simple ACL injuries and procedures. I know some of you’re like, How’s this simple at all when it’s ACL-related? The main thing here is that it would be a little different for someone with a multiple ligament injury like ACL and MCL, or maybe a PCL and LCL involved. I’m saying more so of not a grade two, where those things heal back, but more so like a complete tear of maybe the ACL and the MCL. Or maybe it’s the ACL and the LCL, for example. Those are the lateral ligaments, and then there’s the medial ligament, which is the MCL, and then you have the PCL, which is in the joint itself with the ACL. 

Sometimes, depending on the injury and the mechanism that people can tear multiple. A lot of times, what we’ll see is that the ACL will tear, and then the MCL is typically very common with an ACL injury. And usually it’s not a full tear unless it’s like a really crazy contact impact to the knee, where that knee is forced inward. It’s like a grade I or a grade II to the MCL, which it usually heals, and the surgeon doesn’t need to do anything. And sometimes the meniscus can be involved, which I know many of you listening probably have some sort of meniscus-related impact from the ACL injury. And that could be just a slight tear. It could be a more complicated tear. It also depends on when you have the surgery. Have you had other instability episodes? 

But with that said, I’m thinking more so of a more complex knee that the surgeon is going to have to deal with, whether that’s multiple ligaments, a complex meniscus repair, cartilage repair, or maybe you’re dealing with some type of bone fracture as well. These are more complicated procedures in which bracing might be completely warranted to prevent excess stress or range restrictions to protect all these multiple structures from healing. 

But the most common ACL injuries and procedures are ACL with an allograft or an autograft, with either a meniscus repair or menisectomy. Meniscus repair—they put a stitch down and allow that thing to heal. Menisectomy—they’re going to cut some of it away to smooth it out. And that is going to depend on where that tear is, whether the surgeon feels like they can repair it or not, and give you your best shot. 

And the thing that’s always interesting with bracing is that I talk to just different PT friends in different areas of the country, in the U.S., but then also in other countries like Australia. They say they rarely ever see a brace after ACL reconstruction. This is just interesting. In Australia, we tend to see more hamstring-based grafts than you do the patella tendon or the quad tendon. There’s less quad tendons in general. You’ll see more patella tendons, but hamstring tendons tend to be a more dominant one. And depending on different countries and the training of different surgeons in different regions, they might do multiple; they might just do one. But bracing is not really done often with some of these colleagues that I talked to. That’s the thing that’s always interesting from a bracing standpoint, okay, do we need to brace this ACL that has an allograft, where it is a cadaver tendon? And do we need to brace that? There’s no meniscus repair—what are we trying to protect here? And I know sometimes people think that the braces are going to protect the ACL and the surgery itself, which, yes, to some degree. But if we’re not being dumb post-op, to be completely honest, outside of accidents that can happen, I get that, we are not really at risk for this. And a lot of times, I see this hurt and slow people down more than it helps people. 

Now again, I’m going to do a separate podcast on this, but I’m just going to digress here because I want to get to the point of this episode, which is the illusion a brace can give us post-op. And for you to especially look out for, especially if you’re in these early stages, or maybe you have surgery coming up, or maybe you’re looking in hindsight, and maybe you were someone who is like, Oh, I did do that. Therefore, you have awareness around this, some education, and there could be some game planning around it. 

After the ACL surgery, the knee is straight. No one is typically coming out with a bent knee locked. They’re going to be straight. And sometimes in that long bulky brace and then they’ll have that ACE wrap over the knee. Sometimes, they will not have a brace. I have surgeons here in Atlanta and they don’t brace, and then there are some surgeons who lock this thing up for four to six weeks. I don’t ever understand it , to be honest. But my bias is always, can we please avoid a brace at all costs? But I get in majority of situations because things haven’t been progressed, maybe haven’t been researched as much, maybe this is their training. They want to protect things. Maybe the surgeon had some sort of bad experience where someone tore it doing something and so they were just like, let me just lock you up so you can’t make any dumb decisions.

But with that said, I see it harm more than hurt. But the thing is that with the long brace, you’ll have that bulky brace if you do. Again, depending on the surgeon, procedure, other concomitant procedures where they’re repairing other things, and also their belief in their philosophy and their training.

But with that brace, they want to protect the surgery in the knee. And I do understand that. But often it is locked straight when you do have this brace to start post-op. The biggest mistake that I see is that this is locked into extension and they’re told this, they see this, they feel this. It makes the ACLers assume they have full knee extension and so they work at it less. The problem is that they haven’t been educated on what terminal knee extension is, what the goal should be, which is trying to get the heel pop. Or allowing the back of the knee to touch the surface and getting that heel to lift up and get some space underneath the heel where you are sitting on a flat hardwood surface, if you will, and you can slide a very thin book underneath that heel, at least a piece of paper. That is something that we’re looking for. That means that we have some terminal knee extension and we can get there both passively and actively. And that quad is contracting to be able to do that. And also that the brace isn’t going to achieve that. I think that’s one of the biggest things to educate is that the brace itself just because you’re locked into extension, it sounds like you got extension because you feel it and you’re there, but the brace is not going to achieve that when we are talking about a few degrees of hyperextension.

Now with flexion, it’s more obvious. You can see it visually. You can have a lot more range of motion. Guys, people get to 145 degrees of flexion. You have a lot more degrees to work within and notice those differences in those angles. With extension, it takes a little bit more of a trained eye and a feel, and there’s nuances to it. But when we were talking about those few degrees of whether it’s like plus two, zero, minus two, minus four, the brace isn’t going to automatically put you there, just because it’s set on maybe minus 10 in that brace or even a hyperextended position.

There is give to that post-op brace with the padding in there, you have the ACE wrap on it, and depending on the clothing you have. Especially the quad atrophy, you could literally be in that post-op brace the day after surgery, and then a few days later, your quad could shrink down even more—which is so sad. I know how this personally feels with just seeing your leg turn into a little hot dog. And the thing is that your quad size can change; therefore, even if you’re locked there, like it’s not magically just going to keep you there. There’s a give to all these different structures, which is going to influence that locked position.

Your knee will have a natural slight bend to it while it is locked in that brace and post-op. And I had this same thought when I had my post-op brace after my second ACL. I was locked into extension, and I was supposed to hang out there. The thing is that I was assuming that this knee extension was just going to naturally be there, but I realized I had to work at it to get it there. But this is something that I see all the time. This mistake of ACLers assume that they have the extension because the brace is locked into extension in that setting. This is the bracing illusion that I often see, and knowing you have to work on it to get it back in balance with the other side. 

And to finish this up, it is rare that zero is the goal. I want to make sure I reiterate this: zero extension is not the goal. Ninety to ninety-five percent of humans have hyperextension. That means when we hyperextend our elbows when we straighten out our arms, we have some hyperextension. When we straighten out our knees fully, that knee goes beyond zero into some degrees of hyperextension (what we call the negatives). When I hear that zero is good enough, we have ACLers all the time that we consult and work with, and they’re seeing PT before and a surgeon, that they’re working with, and they’ve been told zero is good enough. Good enough is not good enough in this process, y’all. ACL—you should never say that’s good enough in ACL rehab. That is one thing that I forbid you to say. Because the thing is that you cannot risk this to another ACL injury and go through this process again. So whoever says it’s good enough is not good enough for you. You like what I did there? 

But with that said, it’s so important, y’all. I cannot stress this enough. We hear it all the time: zero is good enough. And some people will even say, Oh, if you go into hyperextension, that’s what caused your ACL injury. And they’ve said that to people who have had contact injuries. And I’m like, bro, if you drive your car out there and someone hits you, could you have done anything to prevent that?

No. Because that is just what an accident is. But the thing is that hyperextension is going to be super important. And zero is not going to be good enough. I don’t care if a PT or a surgeon is telling you that. Yes, we all have our backgrounds in medicine and healthcare. But the thing is, from looking at the human anatomy, the way that we are born, the way that the knee functions, hyperextension is very important. The only caveat I’m going to add here, that it doesn’t apply to the majority of you. I’m going to say maybe 5% if not less, because there are people who are hypermobile, who have hyperflexibility within their joints. They’ll do a Beighton score. It’s something that will also help tell us if they have some connective tissue-type-related things in their body. They are just more stretchy. Therefore, they may have minus 15, minus 20 degrees of hyperextension. 

In these cases, we may not want to get it all the way back. Yes, there’s an excessive amount of hyperextension. But again, 90% to 95% of cases, you are going to want to regain full hyperextension that matches the other side. It’s what we are born with and there’s no research to show: Number one, zero degrees is good. I said that really weird, so I’m going to say it again. Zero degrees is good. There’s no research to show that zero degrees is our target. There is no research to show that prevents injuries by staying at zero degrees. There’s no research that exists on it. Number two, that hyperextension is bad. There’s no research that exists that hyperextension regaining what you were born with, as long as it is not a very excessive amount. Again, going back to the hypermobile people who are maybe 5% of people, that is, hyperextension regaining is going to be normal. We want to regain whatever it is your uninvolved side has gotten. And usually that is going to be the best test for you guys is going to be to sit on a hardwood floor. You’re going to try it into a quad set on your uninvolved side. And that is going to basically tell you what your litmus test is for, what you need to get. And so you do it on your involved side and that is what we need to get it to. 

And the thing that I want to share here is that when you don’t get your hyperextension back, we actually see quite the opposite in the research, which shows your risk of OA goes up, patellofemoral pain goes up, quadricep strength goes down, and then this is something that will also influence your swelling and just activities of daily living and getting back to sports. These are all influenced by not achieving your full hyperextension. So make sure you get it back, and most importantly, don’t let a brace fake you out, assuming it’s in hyperextension and you think that you’re there. This starts day one to work on it actively. If you get your hyperextension and heel pop early, you are ahead of the majority of ACLers in this process, especially if you can get that thing week one, week two. And don’t get me wrong, y’all, there are people who are working on it three months out, six months out. People get scar tissue, clean outs, manipulations. There’s a whole lot of things that happen in this process. I know if you’re listening, there are plenty of you who are not hitting it super early, and that’s okay.

The thing is that you need to make sure you have a game plan for it, making sure that zero is not good enough. Making sure one, you’re also going to see a limp probably progress if you don’t get this thing back because you can’t get full terminal hyperextension. And we just need to make sure you are set up for what’s ahead, but try to do your best to knock this out ASAP. 

ACL rehab is an active process. I don’t care if you go to your in-person PT and they move that thing around, they bend it and they straighten it. At the end of the day, it’s going to be the work that you do that is going to last. Doing stuff to you is not going to make this thing last. Make it budge because you’re the only one that can turn on your quad and really ingrain this thing for the long haul. Make sure that if you’re in that post-op brace, you are working on it actively. Don’t fall for this illusion to think that it’s straight and it’s good. Work on it yourself. Have these litmus tests so you know what is your gold standard and abide by that. And lastly, don’t listen to anyone who says zero is good enough. Find someone else. Until next time team, this is your host, Ravi Patel, signing off.