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Knee brace after meniscus surgery?

post #1 of 19
Thread Starter 
Hello,

Any thoughts on whether or not I should be wearing a brace on my knee? I had a small part of the medial meniscus cut out of my right knee a few months ago. I would appreciate any thoughts from those who may have had a similar surgery, etc.

thanks!
post #2 of 19
I had a good portion of my medial meniscus removed a couple years ago, on the knee I'd previously had my ACL reconstructed on - I'm on permanent knee brace status at this point. Essentially, the way my surgeon described it to me - there's no way my knee can ever be as stable without the meniscus fully there. You can strengthen all you want, but part of the structure and cushion is gone forever. So he basically said to wear the brace forever as long as it isn't causing problems.

It doesn't inhibit my skiing, so I figure I might as well wear them.
post #3 of 19
I had the same surgery about seven years ago and expected to be A-ok after a month or so (after all Joan Benoit Samelson ran the olympic trials marathon 3 weeks after the surgery). Well I found my body had a memory of the injury (surgery) that took a few months to recover from. My knee just did not want to be pushed too hard.
My doctor knows the sports I am into and said a brace was optional. I have never used one or felt I needed one, but that is me.
post #4 of 19

Any thoughts on whether or not I should be wearing a brace on my knee?

Maybe, but perhaps not for the "obvious" reasons that one might assume.

AFAIK, a brace cannot provide much cushioning nor much in the way of stabilization without profoundly limiting normal knee movement.

Instead, knee braces theoretically serve a "proprioceptive" function; that is, they may "remind" your body to protect the knee through the sensations they impart as you move, even if you aren't consciously aware of those sensations. That may in turn decrease the amount of stress and work your body will put upon it, perhaps protecting the knee from further injury.

I know that's a lot of "maybes" and perhaps's, but I searched the medical literature on the subject a few years ago and was impressed by the dearth of objective clinical data on knee braces. Most of what I could find was highly subjective and based upon hypothetical benefits, "experience", and tradition rather than good clinical trials. That's why you may see and get contradictory advice on the subject. Some orthopods prescribe them, some say they're "optional," and a few are brutally honest and will tell you "I don't know; do what you want."

But I haven't reviewed the issue recently; maybe someone has more recent data to share...
post #5 of 19
Well a good brace can prevent hyperextension and lateral movement/impact injuries. It's just twisting injuries that it can't do much for. It's better than nothing, I think.

I will say that my first ortho was totally against any sort of bracing. My current one quotes studies that show that post-op ACL patients who use braces for skiing have a lower incidence of re-injury and thinks that therefore it can't hurt and might help, so he also recommends it for my knee that "only" has had an ACL reconstruction and doesn't have meniscus damage. Who knows.

Also, your surgeon is the only one who really knows what your knee looks like in there... so he/she is the one who can make the best call if you should wear a brace or not, I'd think. I've been back to full activity - dirt biking, racing DH mountain bikes, and lots of skiing, but I figure if he suggests knee braces, and I barely notice that they're on when I'm skiing, I may as well use them. I figure it's like wearing a helmet. Sure - I could still injure myself it a way it won't protect, but it might help significantly in the right situation, it's comfortable and practical, so why not?
post #6 of 19

A brief survey of some of the recent medical literature:

Am J Sports Med. 2004 Dec;32(8):1887-92.
Functional bracing after anterior cruciate ligament reconstruction: a prospective, randomized, multicenter study.

McDevitt ER, Taylor DC, Miller MD, Gerber JP, Ziemke G, Hinkin D, Uhorchak JM, Arciero RA, Pierre PS.

Department of Orthopaedics, Department of the United States Naval Academy, Annapolis, Maryland, USA.

BACKGROUND: Bracing after anterior cruciate ligament reconstruction is expensive and is not proven to prevent injuries or influence outcomes. PURPOSE: To determine whether postoperative functional knee bracing influences outcomes. STUDY DESIGN: Prospective, randomized, multicenter clinical trial. METHODS: One hundred volunteers from the 3 US service academies with acute anterior cruciate ligament tears were randomized into braced or nonbraced groups. Only those subjects with anterior cruciate ligament tears treated surgically within the first 8 weeks of injury were included. Patients with chondral injuries, significant meniscal tears, or multiple knee ligament injuries were excluded. Surgical procedures and the postoperative physical therapy protocols were identical for both groups. The braced group was instructed to wear an off-the-shelf functional knee brace for all cutting, pivoting, or jumping activities for the first year after surgery. RESULTS: Ninety-five subjects were available with a minimum 2-year follow-up. There were no statistically significant differences between groups in knee stability, functional testing with the single-legged hop test, International Knee Documentation Committee scores, Lysholm scores, knee range of motion, or isokinetic strength testing. Two braced subjects had reinjuries, and 3 nonbraced subjects had reinjuries. CONCLUSIONS: In this young, active population, postoperative bracing does not appear to change the clinical outcomes after anterior cruciate ligament reconstruction.

Orthopade. 1999 Jun;28(6):565-70.
[To brace or not to brace? How effective are knee braces in rehabilitation?]

[Article in German]

Martinek V, Friederich NF.

Klinik fur Orthopadische Chirurgie und Traumatologie des Bewegungsapparates, Kantonsspital Bruderholz.

Since the clinical benefit of knee braces has yet to be defined, discussion about braces after reconstructive surgery of the anterior cruciate ligament remains controversial. The use of prophylactic braces in sport did not prove to be effective. In ACL insufficient knee joints, the operative treatment is preferred over the use of functional knee braces. Therefore, the postoperative rehabilitation presents the main application of braces. Modern operative techniques with an initial strong fixation of the ACL graft make a functional postoperative treatment without external fixation possible. In the presented meta-analysis of the literature about knee braces, results from clinical and experimental studies are compared. No published clinical data have shown that braces have any effect on postoperative outcome after ACL-reconstruction. Also, no evidence of a significant bracing effect could be demonstrated in the experimental in vivo or in vitro studies, except a limited stabilizing function for lower shear stress below the physiological loads. Consequently, the systematic use of braces in the rehabilitation after ACL reconstruction cannot be recommended. Orthopedics. 2003 Jul;26(7):701-6; discussion 706. Related Articles, Links
Functional anterior cruciate ligament bracing: a survey of current brace prescription patterns.

Decoster LC, Vailas JC.

New Hampshire Musculoskeletal Institute, Manchester, NH 03101, USA.

This study surveyed orthopedic surgeons regarding anterior cruciate ligament (ACL) bracing practices. Surveys were mailed to 1194 members of the American Orthopaedic Society for Sports Medicine. The return rate was 24% (n = 287). Descriptive analysis revealed that 13% of physicians never brace ACL-reconstructed patients, whereas only 3% never brace ACL-deficient patients. Physicians prescribe off-the-shelf braces more frequently for ACL-deficient patients than ACL-reconstructed patients (P = .000). Half reported bracing less frequently than 5 years ago. The wide range of responses reflects the lack of scientific basis for bracing decisions. Continued research efforts are encouraged. In the interim, the physician's clinical judgment provides the basis for bracing decisions.


Clin J Sport Med. 2000 Apr;10(2):85-8.
Management of injuries to the anterior cruciate ligament: results of a survey of orthopaedic surgeons in Canada.

Mirza F, Mai DD, Kirkley A, Fowler PJ, Amendola A.

Fowler-Kennedy Sport Medicine Clinic, University of Western Ontario and London Health Sciences Centre, Canada.

OBJECTIVE: To identify the approaches to management of anterior cruciate ligament (ACL) injury by Canadian orthopedic surgeons. METHODS: A questionnaire was mailed to 234 physicians randomly chosen from the Canadian Orthopaedic Association directory to obtain the following information: 1) how orthopaedic surgeons diagnose acute hemarthroses; 2) how patients in any of three common ACL injury scenarios would be managed; 3) what variations exist in surgical technique; and 4) how patient variables such as age, gender, and alignment influence the decision-making process. RESULTS: The return rate was 72%, and 56% of respondents were from academic centers. Patients such as those described in the protocol are routinely managed by 80% of the respondents. The diagnosis of acute hemarthrosis is predominantly made by means of clinical examination and radiographs. Magnetic resonance imaging (MRI) is used occasionally by 43% and routinely by 6% of those who responded; arthroscopy is used routinely by 24%. For the competitive athlete with a complete ACL tear, 64% would recommend reconstruction and 33% would recommend bracing and rehabilitation. For reconstruction, 59% would use bone-patellar tendon-bone (B-PT-B) autograft and 32% would use hamstring tendon autograft; 40% would incorporate the ACL stump during reconstruction. Of the respondents, 77% would advocate ACL reconstruction for competitive athletes with chronic ACL injury. Of these, 63% would use B-PT-B autograft and 27% would use hamstring tendons. If bracing and rehabilitation failed, 98% would recommend ACL reconstruction. In ACL reconstruction, synthetic augmentation would be used by 12% in chronic cases and by 16% in acute cases. In making the decision to perform ACL reconstruction, 53% consider limb alignment to be important and 67% consider moderate patellofemoral pain to be important. Seventy-one percent are influenced by patellofemoral pain when choosing a surgical technique, with a trend toward semitendinosis autograft rather than B-PT-B autograft reconstruction. For the 8-year-old child with an acute ACL injury, 63% of the respondents would recommend rehabilitation and bracing. For the 14-year-old, 45% would recommend rehabilitation and bracing and 37% would recommend ACL reconstruction after physeal closure. CONCLUSION: The results of the survey indicate that, with respect to some of the issues, there is a wide variation in management of acute and chronic ACL injuries among Canadian orthopedic surgeons. Future research and randomized, controlled clinical trials should be directed toward these areas.

J Orthop Sports Phys Ther. 2002 Jan;32(1):11-5.
The effect of bracing on proprioception of knees with anterior cruciate ligament injury.

Beynnon BD, Good L, Risberg MA.

Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, McClure Musculoskeletal Research Center, Burlington 05405-0084, USA. bruce.beynnon@uvm.edu

This paper is a comprehensive review on the effect of bandaging, bracing, and neoprene sleeves on knee proprioception following anterior cruciate ligament (ACL) injury and reconstruction with a focus on studies that have measured joint position sense and threshold to detection of passive knee motion. Disruption of the ACL does not appear to alter joint position sense soon after injury, although there is evidence that in some subjects deterioration may occur over time. An ACL tear creates a deficit in the threshold to detection of passive knee motion soon after injury and in those with chronic tears. The magnitude of worsening is less then 1.0 degree of movement in flexion-extension and of questionable concern from a clinical and functional perspective. Application of a functional brace or neoprene sleeve to the ACL-deficient limb does not improve the threshold to detection of passive knee motion; however, application of an elastic bandage to a knee with an ACL tear improves joint position sense. Reconstruction of a torn ACL is associated with a deficit in the threshold to detection of passive knee motion, and during the first year of healing the use of a neoprene sleeve provides improvement. Two years following ACL reconstruction there is no deficit in the threshold to detection of passive knee motion and the use of a brace has no effect on this outcome.

Knee Surg Sports Traumatol Arthrosc. 1997;5(3):157-61.
Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow-up of 78 consecutive patients rehabilitated with or without a brace.

Kartus J, Stener S, Kohler K, Sernert N, Eriksson BI, Karlsson J.

Department of Orthopaedics, Norra Alvsborgs County Hospital, Trollhattan, Sweden.

The aim of this study was to evaluate the effect of a standard postoperative rehabilitation knee brace on function, stability and postoperative complications at the 2-year follow-up after anterior cruciate ligament (ACL) reconstructive surgery. Seventy-eight consecutive patients with a unilateral chronic ACL rupture reconstructed by the same surgeon using the endoscopic "all-inside" technique, patellar tendon autograft and interference screw fixation were included in the study. The rehabilitation followed a standard protocol. Group A included 39 patients who were supplied postoperatively with a knee brace for 4 (range 3-6) weeks. Group B included 39 patients for whom a brace was not used. The median age was 27 (range 16-48) years in group A and 26 (range 14-51) years in group B. The median time period between the injury and the index operation was 24 (range 3-150) months in group A and 18 (range 3-360) months in group B. All 78 patients were re-examined by two independent observers after a median follow-up period of 25 (range 23-28) months in group A and 24 (range 22-27) months in group B. The median KT-1000 total side-to-side difference between the reconstructed and the uninjured knees at 89 N was 3 (range -5.5-11) mm in group A and 3 (range -7-10) mm in group B (NS). When the anterior translation was tested separately at 89 N, the corresponding values were 3 (range -4-13) mm in group A and 3 (range -5-10) mm in group B (NS). The median one-leg hop quotient was 95% (range 50%-167%) of the uninjured leg in group A and 92% (range 64%-119%) in group B (NS). The median Lysholm score was 89 (range 39-100) points in group A and 85 (range 37-100) points in group B (NS). In group A, 27/39 (69%) patients and in group B 21/39 (54%) patients were classified as excellent or good (NS). The median Tegner activity level was 7 (range 3-9) in group A and 6 (range 3-9) in group B (NS). Using the IKDC scale, 27/39 (69%) in group A and 24/39 (62%) in group B were classified as normal or nearly normal (NS). The median sick leave in group A was 62 (range 0-357) days and 59 (range 0-243) days in group B (NS). No serious complications occurred during the first 6 postoperative weeks. Two serious complications were, however, registered after the 6th postoperative week. One patient in group A sustained a rupture of the reconstructed ACL 8 weeks postoperatively (3 weeks after removing the brace), and one patient in group B sustained an undislocated patellar fracture during the 7th postoperative week after a fall. This study indicates that the use of a postoperative rehabilitation brace after an arthroscopic ACL reconstruction did not appear to influence either objective stability or subjective function by the 2-year follow-up.

I found very little and nothing specific on knee braces and isolated meniscal injuries:

Br J Sports Med. 1991 Sep;25(3):159-61.

Evaluation of knee braces in Swedish ice hockey players.

Tegner Y, Lorentzon R.

Department of Orthopaedics, Ermeline Clinic, Lulea, Sweden.

In this retrospective investigation we have determined the rate and types of knee injuries among Swedish ice hockey players, and related these data to the use of knee braces. Thirty-seven of the originally selected 50 hockey teams (74%) of elite or first division calibre took part in the study, and 600 players answered a questionnaire. A total of 254 previous knee injuries sustained while playing hockey were reported by 243 players; tears of the medical collateral ligament (60%), meniscus (15%) or anterior cruciate ligament (12%) were the most commonly reported injuries. Prophylactic knee braces were worn by 138 (23%) of the players. Of these, 122 (88%) had earlier sustained a knee injury, and 16 had not. A total of 17 knee injuries had occurred while the players were wearing a brace. Six of these players had previously uninjured knees while 11 had repeat injury in a brace despite earlier successful rehabilitation or operation. The most common injury in braced knees was a tear of the medial collateral ligament. We conclude that the number of knee injuries is high among Swedish ice hockey players, and that the efficacy of functional knee braces to reduce knee injuries is questionable.

Am J Sports Med. 1986 Jul-Aug;14(4):262-6.

Prophylactic knee bracing in college football.

Hewson GF Jr, Mendini RA, Wang JB.

American football can be harmful to knees. In an attempt to reduce the number and severity of knee injuries, the intercollegiate football team at the University of Arizona (Pacific Ten Conference) has been using protective braces since 1981. Objective evaluation of the effectiveness of this program is the purpose of this study. All linemen, offensive and defensive, as well as linebackers and tight ends were considered to be the players at greatest risk and were required to use the braces. The brace used was the Anderson Knee Stabler. Each player at each practice session or game was counted as one exposure. During the 4 years of brace use, there were 28,191 exposures, while the control group numbered 29,293 exposures. The data were analyzed from the perspectives of days lost from practice or games, player's position, the type and severity of injury, and the rate of injury per 100 players per season. Players at risk showed no trend to change in injury rate. Of the players at risk, the type and severity of injury in nonbraced and in braced groups were similar. A significant finding in players at risk was a two-fold increase in knee ligament injury rate per 100 players when compared to rates for an entire team. The number of season-ending injuries remained unchanged. Practice time missed for third-degree medial ligament, and for medial meniscus injuries, was significantly lower in the braced group, but this was due to improved treatment techniques initiated in 1981. Seven NCAA rule changes, directed at reducing knee injuries, have been introduced since 1981.(ABSTRACT TRUNCATED AT 250 WORDS)
post #7 of 19
Interesting, but those are all about ACL injuries, not meniscus issues. When your ACL is healed, you should be "good as new". When you've had part or all of your meniscus removed, it's never coming back no matter what rehab you're doing.
post #8 of 19
Those are mostly about Knee braces and the lack of objective data demonstrating a postive impact upon ACL repair outcomes; in fact, most of the data shows no effective impact of any kind.

There's even less data on the effect knee braces might have upon meniscal tears, irrespective of concommitant ACL issues.

In other words, there is no good clinical evidence that wearing a knee brace for any period of time after an ACL and/or meniscal repair has any beneficial effect. You can spend the money and effort if you want, but there's no objective medical reason that you should.

The claim that,
Quote:
When your ACL is healed, you should be 'good as new'
...is unfortunately not true if the tear is complete or nearly complete. No intervention at this time can return a completely or almost completely torn ACL to its original state, nor can any technique return the stability that was present prior to the injury irrespective of any injury or repair to the menisci. Whether repaired or not, an ACL tear injury increases one's risk of both subsequent injuries and of osteoarthritis involving the affected joint whether or not there has been injury to the meniscus.

At best, an ACL repair surgery may improve the stability of an injured knee and might forestall the subsequent degenerative changes, but an ACL injury involving a severe tear that is repaired with currently available techniques will never be "as good as new" regardless of the status of the knee's menisci.

And there is no objective evidence of which I am aware that wearing a brace can have any lasting impact upon the outcome of a surgically repaired ACL regardless of whether or not there has been an injury and/or repair done to the menisci, nor does there appear to be any objective data demonstrating that a brace can have any lasting impact upon the outcome of a surgically repaired mensicus regardless of whether or not there has been an injury and/or repair done to the ACL.

There is some evidence that wearing a stabilizing brace may decrease (but not eliminate) the risk of further injury to a knee with a torn ACL that has not been surgically repaired, but that same partial benefit does not appear to be imparted by bracing a knee following a torn ACL that has been surgically repaired.
post #9 of 19
My point is that none of these studies show anything one way or the other about menisectomy patients. Note - not meniscus repair, which is quite different, and would not have an effect on stability.

I agree with you that your knee isn't 100% after ACL recon, but at least the deficiency is corrected with a reconstruction. With a menisectomy (full or partial) it is not - they are just removing the torn or shredded portion of the meniscus so it's not in the way anymore. You are left with an empty space where you used to have a meniscus.

So you should follow your doctor's advice, as he or she knows how much your knee's stability has been affected by what was done and is in the best position to determine if a brace might help.


Also - my two custom knee braces cost me a grand total of $0.00. Insurance paid for them. The only expenditure is that of the couple of minutes it takes to put them on before skiing.

My surgeon told me last February that he had just returned from a conference where they presented a study showing that there was a decreased risk of reinjury for those who wore braces for 2 years after ACL reconstruction. This study was only on skiers, not other sports. It wasn't a massive risk reduction, but it was statistically significant. This was what he based his decision on. I don't have the reference, I just follow my doc's advice since he knows my knees best.
post #10 of 19
If there is ANY objective clincial evidence that a knee brace can positively impact the outcome of ANY type of meniscal surgery or ANY type of ACL surgery in ANY way, that would indeed represent a great achievement; I and many others would love to see it published in the peer-reviewed medical literature. However, in the absence of such data, as one of the abstracts above concluded, "The wide range of responses [from orthopedic physicians regarding their practices] reflects the lack of scientific basis for bracing decisions."
post #11 of 19
There is an article in the Winter 2005 Professional Skier regarding the effects of bracing. If anyone is interested, I will mail them a copy.
Send me your fax # or snail mail.
post #12 of 19
thanks, PM sent.
post #13 of 19

You are just too darn popular...

skier31; I got your return PM, but now your inbox is full and I can't reply back.

Rick
post #14 of 19
Rick, thanks for posting the excerpts from the med journals. I had endoscopic meniscus repair about 4 years ago, and wore a brace for a year or two afterwards. All my sources said 'It might or might not be helpful.' At the time, it had, I think, a positive psychosomatic effect-- Far more helpful, IMHO, was attentively training to build up the supporting muscle groups: quads, hamstrings, abductors, adductors. An investment for the longer term that has without a doubt been beneficial.
post #15 of 19
Rick: Took care of the inbox issue. Thanks.
post #16 of 19
Your welcome, pdxski. And thanks for the article, skier31.

Rick
post #17 of 19

So which brace?

Hi all! So assuming that there is a possible gain and no downside to wearing a brace, does anyone have any recommendations of which one? Donjoy seems to be popular, and I also have the asterisk brace from temecula highly recommended. Any thoughts? By the way, my situation was a torn MCL and partially torn ACL. There seems to be little question that a brace can help prevent MCL damage, agreed?
post #18 of 19
Check out these knee braces. Alot of the pro freeriders wear them with or without a prevous knee injuries. I hear great things about them. I have never tried them personally though.


http://www.mtbz.com/mountainboard_ac...erisk_cell.htm
post #19 of 19
I'd ask your doctor. In addition to getting a professional opinion on which would likely work best for your situation, you can get a prescription and have your insurance cover it.

FWIW - I have 2 Donjoy Defiances. Left knee has had part of the meniscus removed and an ACL reconstructed with a hamstring autograft. Right knee had the ACL reconstructed with an allograft.
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