Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Functional bracing of ACL injuries: current state and future directions

Abstract

Purpose

Functional braces are commonly prescribed to treat anterior cruciate ligament (ACL) injury. The results of the existing literature on functional brace use are mixed. The purpose of this study was to evaluate the history and current state of functional ACL bracing and to identify design criteria that could improve upon current bracing technologies.

Methods

A literature search was performed through the PubMed MEDLINE database in April 2013 for the keywords “anterior cruciate ligament” and “brace”. Articles published between January 1, 1980, and April 4, 2013, were retrieved and reviewed. Current functional braces used to treat ACL injury were identified. The function of the native ACL was carefully studied to identify design requirements that could improve upon current bracing technologies.

Results

Biomechanical evaluations of functional brace effects at time zero have been mixed. Functional brace use reportedly does not improve long-term patient outcomes following ACL reconstruction, but has been shown to reduce subsequent injury rates while skiing in both ACL-deficient and reconstructed skiers. In situ force in the ACL varies with flexion angle and activity. Currently, no brace has been designed and validated to replicate the force-flexion behavior of the native ACL.

Conclusions

Biomechanical and clinical evidence suggests current functional bracing technologies do not sufficiently restore normal biomechanics to the ACL-deficient knee, protect the reconstructed ACL, and improve long-term patient outcomes. Further research into a functional brace designed to apply forces to the knee joint similar in magnitude to the native ACL should be pursued.

Level of evidence

III.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Andersson D, Samuelsson K, Karlsson J (2009) Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials. Arthroscopy 25(6):653–685

  2. 2.

    Ardern CL, Taylor NF, Feller JA, Webster KE (2012) Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med 40(1):41–48

  3. 3.

    Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J Sports Med 39(3):538–543

  4. 4.

    Barrett AM, Craft JA, Replogle WH, Hydrick JM, Barrett GR (2011) Anterior cruciate ligament graft failure: a comparison of graft type based on age and Tegner activity level. Am J Sports Med 39(10):2194–2198

  5. 5.

    Beynnon BD, Fleming BC (1998) Anterior cruciate ligament strain in-vivo: a review of previous work. J Biomech 31(6):519–525

  6. 6.

    Beynnon BD, Fleming BC, Churchill DL, Brown D (2003) The effect of anterior cruciate ligament deficiency and functional bracing on translation of the tibia relative to the femur during nonweightbearing and weightbearing. Am J Sports Med 31(1):99–105

  7. 7.

    Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Renstrom PA, Pope MH (1995) Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 23(1):24–34

  8. 8.

    Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE (2005) Treatment of anterior cruciate ligament injuries, part 2. Am J Sports Med 33(11):1751–1767

  9. 9.

    Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE (2005) Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med 33(10):1579–1602

  10. 10.

    Beynnon BD, Johnson RJ, Fleming BC, Peura GD, Renstrom PA, Nichols CE, Pope MH (1997) The effect of functional knee bracing on the anterior cruciate ligament in the weightbearing and nonweightbearing knee. Am J Sports Med 25(3):353–359

  11. 11.

    Beynnon BD, Johnson RJ, Fleming BC, Renstrom PA, Nichols CE, Pope MH, Haugh LD (1994) The measurement of elongation of anterior cruciate-ligament grafts in vivo. J Bone Joint Surg Am 76(4):520–531

  12. 12.

    Beynnon BD, Johnson RJ, Fleming BC, Stankewich CJ, Renstrom PA, Nichols CE (1997) The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension. A comparison of an open and a closed kinetic chain exercise. Am J Sports Med 25(6):823–829

  13. 13.

    Beynnon BD, Pope MH, Wertheimer CM, Johnson RJ, Fleming BC, Nichols CE, Howe JG (1992) The effect of functional knee-braces on strain on the anterior cruciate ligament in vivo. J Bone Joint Surg Am 74(9):1298–1312

  14. 14.

    Beynnon BD, Uh BS, Johnson RJ, Fleming BC, Renstrom PA, Nichols CE (2001) The elongation behavior of the anterior cruciate ligament graft in vivo. A long-term follow-up study. Am J Sports Med 29(2):161–166

  15. 15.

    Birmingham TB, Bryant DM, Giffin JR, Litchfield RB, Kramer JF, Donner A, Fowler PJ (2008) A randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. Am J Sports Med 36(4):648–655

  16. 16.

    Claes S, Hermie L, Verdonk R, Bellemans J, Verdonk P (2012) Is osteoarthritis an inevitable consequence of anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-012-2251-8

  17. 17.

    Collins JJ, O’Connor JJ (1991) Muscle-ligament interactions at the knee during walking. Proc Inst Mech Eng H 205(1):11–18

  18. 18.

    Colville MR, Lee CL, Ciullo JV (1986) The Lenox Hill brace. An evaluation of effectiveness in treating knee instability. Am J Sports Med 14(4):257–261

  19. 19.

    Cook FF, Tibone JE, Redfern FC (1989) A dynamic analysis of a functional brace for anterior cruciate ligament insufficiency. Am J Sports Med 17(4):519–524

  20. 20.

    Dai B, Butler RJ, Garrett WE, Queen RM (2012) Anterior cruciate ligament reconstruction in adolescent patients: limb asymmetry and functional knee bracing. Am J Sports Med 40(12):2756–2763

  21. 21.

    Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R (1985) Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am 67(5):720–726

  22. 22.

    Daniel DM, Stone ML, Sachs R, Malcom L (1985) Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med 13(6):401–407

  23. 23.

    Decoster LC, Vailas JC (2003) Functional anterior cruciate ligament bracing: a survey of current brace prescription patterns. Orthopedics 26(7):701–706

  24. 24.

    Decoster LC, Vailas JC, Swartz WG (1995) Functional ACL bracing. A survey of current opinion and practice. Am J Orthop (Belle Mead NJ) 24(11):838–843

  25. 25.

    Delay BS, Smolinski RJ, Wind WM, Bowman DS (2001) Current practices and opinions in ACL reconstruction and rehabilitation: results of a survey of the American Orthopaedic Society for Sports Medicine. Am J Knee Surg 14(2):85–91

  26. 26.

    Escamilla RF, Macleod TD, Wilk KE, Paulos L, Andrews JR (2012) Anterior cruciate ligament strain and tensile forces for weight-bearing and non-weight-bearing exercises: a guide to exercise selection. J Orthop Sports Phys Ther 42(3):208–220

  27. 27.

    Ferber R, Osternig LR, Woollacott MH, Wasielewski NJ, Lee JH (2004) Bilateral accommodations to anterior cruciate ligament deficiency and surgery. Clin Biomech (Bristol, Avon) 19(2):136–144

  28. 28.

    Fleming BC, Renstrom PA, Beynnon BD, Engstrom B, Peura G (2000) The influence of functional knee bracing on the anterior cruciate ligament strain biomechanics in weightbearing and nonweightbearing knees. Am J Sports Med 28(6):815–824

  29. 29.

    Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE (2004) Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res 22(1):85–89

  30. 30.

    Granan LP, Bahr R, Steindal K, Furnes O, Engebretsen L (2008) Development of a national cruciate ligament surgery registry: the Norwegian National Knee Ligament Registry. Am J Sports Med 36(2):308–315

  31. 31.

    Granan LP, Forssblad M, Lind M, Engebretsen L (2009) The scandinavian ACL registries 2004–2007: baseline epidemiology. Acta Orthop 80(5):563–567

  32. 32.

    Hamann JC, Ma R, Thompson SR, Hogan MV, Miller MD (2012) What’s new in sports medicine. J Bone Joint Surg Am 94(8):757–765

  33. 33.

    Harrington IJ (1976) A bioengineering analysis of force actions at the knee in normal and pathological gait. Biomed Eng 11(5):167–172

  34. 34.

    Hewett TE, Di Stasi SL, Myer GD (2013) Current concepts for injury prevention in Athletes after anterior cruciate ligament reconstruction. Am J Sports Med 41(1):216–224

  35. 35.

    Hosseini A, Gill TJ, Van de Velde SK, Li G (2011) Estimation of in vivo ACL force changes in response to increased weightbearing. J Biomech Eng 133(5):051004

  36. 36.

    Jackson DW, Grood ES, Goldstein JD, Rosen MA, Kurzweil PR, Cummings JF, Simon TM (1993) A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports Med 21(2):176–185

  37. 37.

    Jordan SS, DeFrate LE, Nha KW, Papannagari R, Gill TJ, Li G (2007) The in vivo kinematics of the anteromedial and posterolateral bundles of the anterior cruciate ligament during weightbearing knee flexion. Am J Sports Med 35(4):547–554

  38. 38.

    Kanamori A, Woo SL, Ma CB, Zeminski J, Rudy TW, Li G, Livesay GA (2000) The forces in the anterior cruciate ligament and knee kinematics during a simulated pivot shift test: a human cadaveric study using robotic technology. Arthroscopy 16(6):633–639

  39. 39.

    Kar J, Quesada PM (2012) A numerical simulation approach to studying anterior cruciate ligament strains and internal forces among young recreational women performing valgus inducing stop-jump activities. Ann Biomed Eng 40(8):1679–1691

  40. 40.

    Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ (2004) Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med 32(3):629–634

  41. 41.

    Kocher MS, Sterett WI, Briggs KK, Zurakowski D, Steadman JR (2003) Effect of functional bracing on subsequent knee injury in ACL-deficient professional skiers. J Knee Surg 16(2):87–92

  42. 42.

    Lawrence JT, Argawal N, Ganley TJ (2011) Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? Am J Sports Med 39(12):2582–2587

  43. 43.

    Li G, Defrate LE, Rubash HE, Gill TJ (2005) In vivo kinematics of the ACL during weight-bearing knee flexion. J Orthop Res 23(2):340–344

  44. 44.

    Li G, DeFrate LE, Sun H, Gill TJ (2004) In vivo elongation of the anterior cruciate ligament and posterior cruciate ligament during knee flexion. Am J Sports Med 32(6):1415–1420

  45. 45.

    Li G, Rudy TW, Sakane M, Kanamori A, Ma CB, Woo SL (1999) The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL. J Biomech 32(4):395–400

  46. 46.

    Li G, Zayontz S, Most E, DeFrate LE, Suggs JF, Rubash HE (2004) In situ forces of the anterior and posterior cruciate ligaments in high knee flexion: an in vitro investigation. J Orthop Res 22(2):293–297

  47. 47.

    Lind M, Menhert F, Pedersen AB (2009) The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 17(2):117–124

  48. 48.

    Lind M, Menhert F, Pedersen AB (2012) Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med 40(7):1551–1557

  49. 49.

    Lobenhoffer P (1999) Knee ligament injuries. Anatomy, biomechanics, diagnosis, indications. Chirurg 70(2):219–230

  50. 50.

    Logerstedt D, Lynch A, Axe MJ, Snyder-Mackler L (2013) Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21(4):859–868

  51. 51.

    Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG (2009) Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 91(10):2321–2328

  52. 52.

    Markolf KL, Burchfield DM, Shapiro MM, Cha CW, Finerman GA, Slauterbeck JL (1996) Biomechanical consequences of replacement of the anterior cruciate ligament with a patellar ligament allograft. Part II: forces in the graft compared with forces in the intact ligament. J Bone Joint Surg Am 78(11):1728–1734

  53. 53.

    McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD, Reinke EK (2012) Return to high school-and college-level football after anterior cruciate ligament reconstruction: a multicenter orthopaedic outcomes network (MOON) cohort study. Am J Sports Med 40(11):2523–2529

  54. 54.

    McDevitt ER, Taylor DC, Miller MD, Gerber JP, Ziemke G, Hinkin D, Uhorchak JM, Arciero RA, Pierre PS (2004) Functional bracing after anterior cruciate ligament reconstruction: a prospective, randomized, multicenter study. Am J Sports Med 32(8):1887–1892

  55. 55.

    Miura K, Woo SL, Brinkley R, Fu YC, Noorani S (2006) Effects of knee flexion angles for graft fixation on force distribution in double-bundle anterior cruciate ligament grafts. Am J Sports Med 34(4):577–585

  56. 56.

    Moksnes H, Engebretsen L, Risberg MA (2012) Management of anterior cruciate ligament injuries in skeletally immature individuals. J Orthop Sports Phys Ther 42(3):172–183

  57. 57.

    Muramatsu K, Hachiya Y, Izawa H (2008) Serial evaluation of human anterior cruciate ligament grafts by contrast-enhanced magnetic resonance imaging: comparison of allografts and autografts. Arthroscopy 24(9):1038–1044

  58. 58.

    Nicholas JA (1983) Bracing the anterior cruciate ligament deficient knee using the Lenox Hill derotation brace. Clin Orthop Relat Res 172:137–142

  59. 59.

    Owings MF, Kozak LJ (1998) Ambulatory and inpatient procedures in the United States. Vital Health Stat 13(139):1–119

  60. 60.

    Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE (2010) Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med 38(10):1968–1978

  61. 61.

    Petersen W, Tretow H, Weimann A, Herbort M, Fu FH, Raschke M, Zantop T (2007) Biomechanical evaluation of two techniques for double-bundle anterior cruciate ligament reconstruction. Am J Sports Med 35(2):228–234

  62. 62.

    Pietrini SD, Ziegler CG, Anderson CJ, Wijdicks CA, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF (2011) Radiographic landmarks for tunnel positioning in double-bundle ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 19(5):792–800

  63. 63.

    Risberg MA, Holm I, Steen H, Eriksson J, Ekeland A (1999) The effect of knee bracing after anterior cruciate ligament reconstruction. A prospective, randomized study with 2 years’ follow-up. Am J Sports Med 27(1):76–83

  64. 64.

    Sakane M, Fox RJ, Woo SL, Livesay GA, Li G, Fu FH (1997) In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res 15(2):285–293

  65. 65.

    Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K (2005) Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy 21(8):948–957

  66. 66.

    Seon JK, Gadikota HR, Wu JL, Sutton K, Gill TJ, Li G (2010) Comparison of single- and double-bundle anterior cruciate ligament reconstructions in restoration of knee kinematics and anterior cruciate ligament forces. Am J Sports Med 38(7):1359–1367

  67. 67.

    Serpas F, Yanagawa T, Pandy M (2002) Forward-dynamics simulation of anterior cruciate ligament forces developed during isokinetic dynamometry. Comput Methods Biomech Biomed Eng 5(1):33–43

  68. 68.

    Shah VM, Andrews JR, Fleisig GS, McMichael CS, Lemak LJ (2010) Return to play after anterior cruciate ligament reconstruction in National Football League athletes. Am J Sports Med 38(11):2233–2239

  69. 69.

    Shao Q, MacLeod TD, Manal K, Buchanan TS (2011) Estimation of ligament loading and anterior tibial translation in healthy and ACL-deficient knees during gait and the influence of increasing tibial slope using EMG-driven approach. Ann Biomed Eng 39(1):110–121

  70. 70.

    Shelbourne KD, Klotz C (2006) What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction. J Orthop Sci 11(3):318–325

  71. 71.

    Shelburne KB, Pandy MG (1997) A musculoskeletal model of the knee for evaluating ligament forces during isometric contractions. J Biomech 30(2):163–176

  72. 72.

    Shelburne KB, Pandy MG (1998) Determinants of cruciate-ligament loading during rehabilitation exercise. Clin Biomech (Bristol, Avon) 13(6):403–413

  73. 73.

    Shelburne KB, Pandy MG (2002) A dynamic model of the knee and lower limb for simulating rising movements. Comput Methods Biomech Biomed Eng 5(2):149–159

  74. 74.

    Shelburne KB, Pandy MG, Anderson FC, Torry MR (2004) Pattern of anterior cruciate ligament force in normal walking. J Biomech 37(6):797–805

  75. 75.

    Stanley CJ, Creighton RA, Gross MT, Garrett WE, Yu B (2011) Effects of a knee extension constraint brace on lower extremity movements after ACL reconstruction. Clin Orthop Relat Res 469(6):1774–1780

  76. 76.

    Sterett WI, Briggs KK, Farley T, Steadman JR (2006) Effect of functional bracing on knee injury in skiers with anterior cruciate ligament reconstruction: a prospective cohort study. Am J Sports Med 34(10):1581–1585

  77. 77.

    Theoret D, Lamontagne M (2006) Study on three-dimensional kinematics and electromyography of ACL deficient knee participants wearing a functional knee brace during running. Knee Surg Sports Traumatol Arthrosc 14(6):555–563

  78. 78.

    Toutoungi DE, Lu TW, Leardini A, Catani F, O’Connor JJ (2000) Cruciate ligament forces in the human knee during rehabilitation exercises. Clin Biomech (Bristol, Avon) 15(3):176–187

  79. 79.

    Urbach D, Nebelung W, Becker R, Awiszus F (2001) Effects of reconstruction of the anterior cruciate ligament on voluntary activation of quadriceps femoris a prospective twitch interpolation study. J Bone Joint Surg Br 83(8):1104–1110

  80. 80.

    van Eck CF, Schkrohowsky JG, Working ZM, Irrgang JJ, Fu FH (2012) Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft. Am J Sports Med 40(4):800–807

  81. 81.

    van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ (2010) Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18(8):1128–1144

  82. 82.

    Wojtys EM, Kothari SU, Huston LJ (1996) Anterior cruciate ligament functional brace use in sports. Am J Sports Med 24(4):539–546

  83. 83.

    Woo SL, Abramowitch SD, Kilger R, Liang R (2006) Biomechanics of knee ligaments: injury, healing, and repair. J Biomech 39(1):1–20

  84. 84.

    Woo SL, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu FH (2002) The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon. A cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am 84-A(6):907–914

  85. 85.

    Wu GK, Ng GY, Mak AF (2001) Effects of knee bracing on the sensorimotor function of subjects with anterior cruciate ligament reconstruction. Am J Sports Med 29(5):641–645

  86. 86.

    Wu JL, Hosseini A, Kozanek M, Gadikota HR, Gill TJT, Li G (2010) Kinematics of the anterior cruciate ligament during gait. Am J Sports Med 38(7):1475–1482

  87. 87.

    Wu JL, Seon JK, Gadikota HR, Hosseini A, Sutton KM, Gill TJ, Li G (2010) In situ forces in the anteromedial and posterolateral bundles of the anterior cruciate ligament under simulated functional loading conditions. Am J Sports Med 38(3):558–563

  88. 88.

    Yu B, Herman D, Preston J, Lu W, Kirkendall DT, Garrett WE (2004) Immediate effects of a knee brace with a constraint to knee extension on knee kinematics and ground reaction forces in a stop-jump task. Am J Sports Med 32(5):1136–1143

  89. 89.

    Zampeli F, Pappas E, Giotis D, Hantes ME, Georgoulis AD (2012) Kinematic predictors of subjective outcome after anterior cruciate ligament reconstruction: an in vivo motion analysis study. Knee Surg Sports Traumatol Arthrosc 20(4):785–792

  90. 90.

    Ziegler CG, Pietrini SD, Westerhaus BD, Anderson CJ, Wijdicks CA, Johansen S, Engebretsen L, LaPrade RF (2011) Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. Am J Sports Med 39(4):743–752

Download references

Acknowledgments

We would like to thank Barry Eckhaus for the images presented in this article. We would also like to thank Molly McGee of Medequip, Inc., for her contributions to the pricing information in Table 1.

Conflict of interest

The authors declare they have no conflict of interest.

Author information

Correspondence to Coen A. Wijdicks.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Smith, S.D., LaPrade, R.F., Jansson, K.S. et al. Functional bracing of ACL injuries: current state and future directions. Knee Surg Sports Traumatol Arthrosc 22, 1131–1141 (2014). https://doi.org/10.1007/s00167-013-2514-z

Download citation

Keywords

  • Anterior cruciate ligament
  • Functional brace
  • Deficiency
  • Reconstruction