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Immediate and 6-week effects of wearing a knee sleeve following anterior cruciate ligament reconstruction: a cross-over laboratory and randomised clinical trial

Abstract

Background

Rehabilitation following anterior cruciate ligament (ACL) reconstructions is based mainly on comprehensive progressive exercise programmes using a multi-dimensional approach. Elastic knee sleeves may be useful adjuncts to rehabilitation. The aim of this study was to determine the immediate and 6-week effects of wearing a knee sleeve on person-reported outcomes and function in participants who had undergone an ACL reconstruction and who had residual self-reported functional limitations.

Methods

Individuals with ACL reconstruction in the previous 6 months to 5 years were recruited. Immediate effects of a commercially-available elastic knee sleeve on single-leg horizontal hop distance were explored using a cross-over design. Following this first session, participants were randomised into a Control Group and a Sleeve Group who wore the sleeve for 6 weeks, at least 1 h daily. Outcome measures for the randomised clinical trial (RCT) were the International Knee Documentation Classification Subjective Knee Form (IKDC-SKF) score, the single-leg horizontal hop distance, and isokinetic quadriceps and hamstring peak torque. Linear mixed models were used to determine random effects. Where both limbs were measured at multiple time points, a random measurement occasion effect nested within participant was used.

Results

Thirty-four individuals (16 women) with ACL reconstruction completed the cross-over trial. Hop distance for the injured side during the sleeve condition increased by 3.6 % (95 % CI 0.4–6.8 %, p = 0.025). There was no evidence of differential changes between groups for the IKDC-SKF (Sleeve Group n = 15; Control Group n = 16; p = 0.327), or relative improvement in the injured side compared to the uninjured side for the physical performance measures (Sleeve Group n = 12, Control Group n = 12; three-way interaction p = 0.533 [hop distance], 0.381 [quadriceps isokinetic peak torque], and 0.592 [hamstring isokinetic peak torque]).

Conclusions

Single-leg hop distance of the ACL reconstructed side improved when wearing a knee sleeve. Wearing the knee sleeve over 6 weeks did not lead to enhanced improvements in self-reported knee function, hop distance and thigh muscle strength compared to the control group.

Trial registration

The trial was prospectively registered with the Australia New Zealand Clinical Trials Registry No: ACTRN12618001083280, 28 June 2018.

Peer Review reports

Background

Anterior cruciate ligament (ACL) ruptures are debilitating knee injuries, potentially with devastating short-term and long-term consequences. Surgical ACL reconstruction and rehabilitation remains the primary approach for active individuals with such ruptures [1]. Reported annual incidence rates per 100,000 person-years for ACL surgeries are 68.6 in the USA [2], 58.2 in New Zealand [3], 52.0 in Australia [4], and 32.0 in Sweden [5]. Different procedures and grafts have been described for the surgical ACL reconstruction. In New Zealand, hamstring tendon grafts account for 71 % of all primary ACL reconstructions, followed by patellar tendon grafts (24 %), and quadriceps tendon grafts (3 %), with allografts used infrequently [6]. Irrespective of graft type, risk of a subsequent ACL rupture ranges between 6 and 15 % [7]. Over 50 % of individuals develop symptoms of knee osteoarthritis within 15 years of reconstruction [8].

Besides the risk of re-injury and knee osteoarthritis, medium to long-term impairments and restrictions following ACL reconstruction have been reported. Cross-sectional studies suggest persistent thigh muscle strength deficits [9, 10], altered movement patterns [11], and lowered levels of physical activity [12] following ACL reconstruction. While muscle strength deficits are dependent on the graft harvest site within 5 or less years following surgery [13, 14], that is less likely in the long term (10 or more years) [15]. Activity levels also appear to decline over time [16]. Long term decreased knee-related quality of life, fear of re-injury and loss of confidence is often experienced following ACL reconstruction [10, 17,18,19].

Rehabilitation following ACL reconstruction involves multiple elements, such as progressive physical rehabilitation of muscle strength, neuromuscular control, sports- and work-related specific skills and gradual return to physical activity, sports and work [20]. Adjuncts that can be used for rehabilitation following ACL reconstruction are knee braces or sleeves. Historically, rigid knee braces were used as part of early rehabilitation following ACL reconstruction to protect the graft, however, that such braces do not appear to improve clinical outcomes and are no longer prescribed routinely [21, 22]. The use of elastic or neoprene sleeves may be used during rehabilitation post-ACL reconstruction for return to sports [23]. Laboratory studies exploring the efficacy of knee sleeves have focussed on participants with knee osteoarthritis [24] and healthy knees [25]. Results suggest that use of such sleeves may improve function-related performance for symptomatic knees [24, 25], potentially by improving sensorimotor control [26], as well as by improving the individual’s confidence in their knee [25, 27].

The aim of this study was to determine immediate and 6-week effects of wearing a knee sleeve on person-reported outcomes and function in participants who had undergone an ACL reconstruction in the previous 6 months to 5 years, specifically for individuals who had residual self-reported functional limitations. The primary research hypothesis was that single-leg hop distance of the ACL-reconstructed side would improve when wearing a sleeve compared to not wearing the sleeve and compared to the contralateral uninjured side. Secondary hypotheses were that self-reported knee-related symptoms and function would improve to a larger extent over a 6-week period in a group of participants that used the knee sleeve on a daily basis, compared to a control group that did not wear such a sleeve. Lastly, we hypothesised that deficits of the single-leg hop distance and thigh muscle strength would improve to a greater extent for the group wearing the knee sleeve than the control group over the 6-week period.

Methods

Data were collected during two sessions (baseline and 6-week follow-up) in a University research laboratory and via REDCap (Research Electronic Data Capture, hosted by the University of Otago, Dunedin, New Zealand). CONSORT reporting guidelines were followed [28]. All procedures were performed in accordance to relevant guidelines.

Trial design and blinding

This study had two linked parts and all participants were involved in both parts. Part 1 consisted of a cross-over laboratory-based study, to examine immediate effects of the wearing of the knee sleeve on single-leg hop distance. Part 2 entailed a parallel two-armed, assessor-blinded randomised clinical trial (RCT), to determine the effects of wearing the knee sleeve over a 6-week period on self-reported knee function and physical performance measures. For the laboratory sessions, it was impossible to blind participants and assessors to the sleeve condition. The research assistant and biostatistician involved in the study were blinded to group allocation for the RCT.

Participants

Recruitment

Participants were recruited via community advertising and using the research participant recruitment agency TrialFacts (https://trialfacts.com/). Volunteers completed a questionnaire (also serving as screening for eligibility) via REDCap prior to attending the first laboratory session. The questionnaire included demographics, injury and surgery history, the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) [29] and the Tegner activity scale [30]. The Tegner scale categorises sports and physical activity in terms of the level of knee-related loading where ‘0’ indicates ‘sick leave or disability due to a knee injury’ and ‘10’ indicates ‘competitive soccer or rugby at national or international elite level’.

Inclusion criteria

We recruited men and women, aged 18–40 years, who underwent ACL reconstruction within 6 months to 5 years previously. We specifically sought individuals who had not yet reached full functional level, defined for the purpose of this study by a score between 40 and 80/100 on the IKDC-SKF [29, 31, 32].

Exclusion criteria

Participants were excluded if they had undergone a revision ACL reconstruction of the same knee (due to re-injury), or a previous ACL reconstruction of the opposite knee; self-reported any other lower limb, pelvic or low back musculoskeletal injuries or disorders that required medical care over the past 6 months; had known systemic, neurological or cardiovascular disorders; or had a body mass index (BMI) above 30 kg/m2. Participants found to have an IKDC-SKF score less than 40 (due to potential safety risk during the laboratory-based tasks) or greater than 80/100 (as use of a sleeve would clinically be less likely to add benefit) were excluded.

Procedures

Randomisation

Participants were individually randomised twice (once for the cross-over trail, and once for the RCT) with equal numbers in each group for both allocations. Block randomisation (in groups of 8 participants) was undertaken sequentially by a research officer using an electronic random number generator prior to participants being entered into the study. Each group was stratified by sex. The research officer informed the researcher responsible for the laboratory data collection of the order for the conditions for the cross-over trial, and the group allocation (for the RCT) via email prior to the start of the individual participant’s first laboratory session.

Eligibility to be included was confirmed and participants provided written informed consent at the start of the first session. Participants were asked to be dressed in a singlet, a pair of shorts and their own sport shoes. Body mass and height were measured during the baseline session.

Part 1: Laboratory cross-over trial

Participants practised the hopping task at sub-maximal distance with the uninjured and injured sides until they were confident with performing them as part of familiarisation and warm-up. They performed the horizontal hop with the injured side under the (1) ‘control’ condition (no sleeve) and (2) the ‘sleeve’ condition (experimental, wearing the sleeve condition), ordered by randomisation. A 5-minute walk between the conditions provided a standardised run-in to the second condition to minimise carryover effects. On completion of the hopping tasks, the participants underwent the isokinetic thigh muscle strength assessment.

Part 2 Randomised clinical trial

Participants were informed of their group allocation for the RCT on completion of the first laboratory session. Following the 6-week period, all participants were asked to return to the laboratory to repeat the above assessments, repeating the hopping tasks (without wearing the knee sleeve) and isokinetic muscle strength tests. Prior to the session, they were sent an electronic REDCap link for the follow-up IKDC-SKF, and they were requested to return their Excel spreadsheet diary to the research officer via email.

Intervention

The intervention entailed use of a commercially available knee sleeve (company anonymised), a CE-certified medical device. The sleeve consists of flexible elastic/knitted materials to provide support to the knee without restricting the range of motion. For Part 1 (cross-over trial), all participants performed the horizontal single-leg hop with and without the sleeve. For Part 2 (RCT), participants of the ‘Sleeve Group’ (intervention) were instructed to wear the knee sleeve while performing their rehabilitative exercises, physical activity and sports, with a minimum of 1 h per day for the 6-week period; the control group were not provided with a sleeve during this period.

Use of the knee sleeve was explained to the ‘Sleeve group’ participants by the researcher and they were provided an instructional leaflet. They were informed to discontinue use if any side-effects evolved, such as discomfort during use, swelling, pain or burning sensations of the knee, leg, or foot, and to contact a researcher should such complaints arise.

The weekly physical activity may be a confounder for the 6-week outcomes. Thus, participants of both groups were asked to complete a physical activity and exercise diary, documenting the nature, duration and intensity (moderate/hard) of exercises, physical activities and sports involvement over the 6-week period using an Excel spreadsheet (Microsoft Corp, Redmont, WA, USA). Participants of the Sleeve Group were also asked to record the daily duration of wearing the knee sleeve. Participants of both groups still undergoing rehabilitation were encouraged to continue with the programme prescribed by their clinician.

Outcomes

For Part 1, the primary outcome was the maximal horizontal hop of the injured side and as a deficit compared to the uninjured side. For Part 2, the primary outcome was the IKDC-SKF [29], and secondary outcomes were the maximal horizontal hop, quadriceps and hamstring muscle strength.

Horizontal hop

The participant was asked to stand on one leg and to hop as far as they can, landing on that leg (Additional file 1: Appendix 1) [33]. No restrictions were placed on arm movements and participants were asked to hold the landing position for 2 s [34]. If they did not hold the position, the trial was repeated until three successful hops had been performed for each leg and condition. The distance was measured in centimetres from the toe at push-off to the heel on landing. For Part 1, three trials were performed for the injured side without wearing the sleeve and while wearing the sleeve, respectively. The average distance of the three trials for each side and condition were calculated.

International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) [29, 31]

This self-report questionnaire consists of 18 questions relating to knee symptoms, function and sports activities. The summed score is on a scale from 1 to 100. Higher scores indicate lower levels of symptoms and higher levels of function and sports activities.

Quadriceps and hamstring muscle strength

Quadriceps and hamstring strength was assessed for both sides with an isokinetic dynamometer (Biodex System 3 Pro, Biodex Medical Systems, Inc, Shirley, NY) using previously reported methods [35]. The participant was in a seated position and performed five reciprocal concentric contractions for the knee extensors (quadriceps) and flexors (hamstrings) at 60°/s. The Biodex System 3 DBM (Version 1.7) system software was used to process peak torque for the quadriceps and the hamstrings for the injured and the uninjured sides.

Sample size

Part 1

Given the reported test-retest Intraclass Correlation Coefficient (ICC) of 0.95 for the horizontal hop distance (Additional file 1: Appendix 1 [33]), a conservative correlation was assumed between repeated measures of 0.8 for Part 1. The sample size of 32 participants (all 32 participants receiving both conditions) allowed 80 % power to detect a 0.33 SD difference between the sleeve and no-sleeve conditions using a two-sided test of means at the 0.05 level. This is between a small (0.2 SD) and moderate (0.5 SD) effect size.

Part 2

To allow for a weaker correlation between repeated measures of 0.7 and up to 10 % attrition, the sample size would permit a 80 % power to detect differences in changes between the Sleeve Group and the Control Group of 0.86 SD using a two-sided test of means at the 0.05 level, slightly larger than a large effect size (0.8 SD).

Data analysis

Demographic data were presented descriptively (means and standard deviations for approximately normally distributed continuous variables; geometric means and standard deviations for approximately log-normally distributed continuous variables; medians and interquartile ranges for other continuous variables; and counts and percentages for categorical variables).

Data from the daily exercise/sports diary were expressed in metabolic equivalents (METs) x minutes per week. METs expresses energy cost of physical activities as multiples of metabolic rate [36]. One MET represents an individual’s energy expenditure while sitting quietly and is approximately to 3.5 mL O2.kg− 1.min− 1 (oxygen consumption per kilogram body mass per minute) [36]. The average weekly MET.min were compared between groups, as well as between participants who completed their physical activity during the COVID19 lockdown period and those who were not influenced by the lockdown. Demographic and diary data were analysed using SPSS Version 24.0 (IBM Corp, Armonk, NY).

Hop distance and muscle strength measurements were logarithmically transformed and analyses were adjusted for participant sex, surgery type, and time since surgery (as a continuous measure), and for Part 1 (cross-over trial) only, a sequence effect. Analyses for the IKDC, hop distance and muscle strength are from linear mixed models using Restricted Maximum Likelihood (REML) to estimate random effects. A random participant effect and, where both limbs are measured at multiple time points, a random measurement occasion effect nested within participant. For hop distance, quadriceps and hamstrings peak torque, interaction effects for injured leg with sleeve at follow-up (three-way interaction) and interaction effect for sleeve at follow-up (two-way interaction) are presented as ratios of the geometric means. Reported effects are for changes and, for Part 2, baseline values were incorporated in the model. These analyses were performed with Stata (16.1, StataCorp LLC, College Station, Texas, USA).

Results

One hundred and twenty-eight volunteers responded to community (n = 50) and TrialFacts (n = 78) advertising. Of those, 34 were eligible, and were assessed at baseline (Part 1). Reasons for exclusion are provided in Additional file 1: Appendix 2. Two participants of the Sleeve Group withdrew from the study following that assessment due to knee re-injuries, unrelated to use of the knee sleeve (Fig. 1). A further eight participants were affected by the COVID-19 lockdown in New Zealand in March/April 2020: one control participant withdrew from the RCT; seven (Sleeve Group n = 3; Control Group n = 4) continued and completed their physical activity diaries during lockdown. They completed the follow-up IKDC-SKF, but could not attend the second laboratory session. Post-lockdown, recruitment continued and seven participants were included in the study (total n = 34). Thirty-one participants completed the follow-up IKDC-SKF (primary outcome for the RCT), of which 24 participants completed the follow-up biomechanical laboratory session (Fig. 1). Demographic data of the participants are provided in Table 1.

Fig. 1
figure 1

Flowchart of participant recruitment, allocation and follow-up. *Participants were lost to the laboratory-based follow-up data collection due to the COVID-19 lockdown in March/April 2020. IKDC-SKF: International Knee Documentation Committee Subjective Knee Form

Table 1 Demographic data (n = 34)

Part 1 Cross-over trial: immediate effects of wearing the knee sleeve

Hop distance increased during the sleeve condition on the injured side by 3.6 % (95 % CI 0.4–6.8 %, p = 0.025) (Table 2). The hop distance deficit between the uninjured and the injured side improved from − 9.3 % (-12.4, -6.1 %) without the sleeve to 6.0 % (-9.2, -2.8 %) with the sleeve. This is equivalent to a 5 cm increased performance for the injured limb when wearing the sleeve compared to not wearing the sleeve.

Table 2 Hop distance (cm) for the uninjured side and for the injured side (with and without the sleeve) (n = 34)

Part 2 randomised clinical trial

For the IKDC-SKF score, there was no evidence of differential changes between the Control Group and the Sleeve Group (interaction p = 0.327) (Table 3). There was no evidence of differences between participants of the Sleeve Group and Control Group in terms of relative improvement in the injured side compared to the uninjured side for the physical performance measures (three-way interaction p values were 0.533 [hop distance], 0.381 [quadriceps isokinetic peak torque], and 0.592 [hamstring isokinetic peak torque]) (Table 3). There was no evidence of differences in absolute improvement for the injured side (two-way interaction p values for this side were 0.741, 0.060, and 0.338, respectively).

Table 3 Means (SD) of physical outcome measures for the Control and Sleeve Groups at Baseline and 6-week Follow-up

Twenty-six participants (76 %) returned their physical activity diary. Participants of the Sleeve Group reported higher average weekly METs.minutes than the Control group (Table 1). There was no statistical difference for the weekly METs.minutes between those that completed the trial during the COVID-19 lockdown (n = 5; median 6,178 MET.min.wk− 1, range 488, 14,347) and the remaining participants (n = 21; median 5,041 MET.min.wk− 1, range 773, 10,851; p = 0.850). Fifteen of the Sleeve Group participants reported wearing the sleeve for a median of 92 min per day (range 42, 434 min).

Discussion

This study explored whether wearing a knee sleeve had immediate effects on hop distance performance for participants with an ACL reconstruction. The hop distance for the injured side improved by 3.6 % while wearing the sleeve, a 5-cm increase. The deficit, when comparing the hop distance of the injured sides to the uninjured sides, improved by approximately one-third. We also investigated whether a group of such participants wearing the knee sleeve daily for 6 weeks had improved self-reported knee function and physical measures to a greater extent than a control group who was not provided with such sleeve. The results showed that wearing the sleeve did not lead to enhanced improvements in self-reported knee function, hop distance and thigh muscle strength compared to the control group who did not receive that sleeve.

Participants

The participants had IKDC-SKF scores well below the normative values (85–90) [37] for individuals up to 35 years old, below the defined patient-acceptable state of 85 [38]. The baseline and follow-up scores were similar to previously reported scores for athletes who had not returned to pre-injury levels of sports (73.4, SD 12.3) [39]. The Tegner activity scores ranged from only able to ‘walk on uneven ground’ (2/10) to having returned to competitive team sports (9/10). The diaries showed that most participants were engaged in regular physical activity while two controls did not meet the guidelines for physical activity of at least 1,000 MET.min.wk− 1 [36]. Participants of the Sleeve Group reported higher levels of physical activity than the Controls. We do not know whether higher BMI for the Controls (Table 1) suggests that they also had lower levels of physical activity prior to entry into the study. It is possible that being offered a sleeve as part of the trial may have motivated participants of the Sleeve Group to increase their physical activity. However, that remains speculative.

Immediate effects on hop distance

Single-leg horizontal hop performance may be part of a clinical assessment for patients with ACL reconstruction to assess recovery progress and to determine readiness for return to sports [39, 40]. The findings indicate that a knee sleeve may be useful for people with ACL reconstruction who have residual functional limitations, potentially gaining an immediate small physical improvement. Participants displayed an average hop distance deficit (compared to uninjured sides) ≤ 10 % in this study, which could be considered a successful outcome following reconstruction [41]. However, the distance hopped on the uninjured sides was well below a distance of 187 cm reported for uninjured participants of a similar age group [42]. When interpreting deficits between the injured and uninjured sides, the findings of the latter also need to be considered. Contralateral decreased strength and functional impairments have been described following ACL injury [43,44,45]. Such changes in the contralateral side are likely due to a combination of central and peripherally mediated mechanisms, as well as lower post-injury levels of physical activity [45, 46]. The mean improvement for the horizontal hop with the sleeve (3.6 %) was marginally greater than a reported standard error of measurement of 3.0 %, and well below a minimal detectable difference of 8 % [34]. Caution is needed in interpretation of these results.

It is unlikely that mechanisms underlying any influences of the knee sleeve are based on mechanical factors due to low mechanical stiffness of the sleeve [24]. As demonstrated in previous laboratory-based studies, wearing a sleeve can enhance knee flexion angles and influence frontal plane biomechanics during walking in participants with knee osteoarthritis [24, 47]. Improvement may also be evident for active joint reposition sense, a proprioceptive variable [25]. One study explored immediate effects of wearing a silicone sleeve in 13 participants within one month of undergoing ACL reconstruction. Passive joint repositioning and isokinetic quadriceps and hamstring muscle strength were reported to be enhanced when compared to no intervention [48]. Collectively, findings indicate that wearing the sleeve may have an influence on sensorimotor control, potentially leading to immediate enhanced movement patterns [24, 26, 47, 48].

Randomised clinical trial: six-week effects of wearing the sleeve

The lack of significant between-group changes for the IKDC-SKF and the physical measures is likely due to multi-factorial influences for recovery, including injury-related, contextual, physical, and psychosocial influences. With the exception of BMI (and, marginally, body mass), the groups were similar in terms of age, sex ratio, time since injury and reconstruction (Table 1). But a wide range was evident for all outcome measures (Table 2), indicating individual participant variability. Similarly, the self-reported use of the knee sleeve ranged from marginally less than the required average 1-hour per day to wearing the sleeve for close to 8 h per day. Such individual variability and personal contexts may have influenced the between-group comparisons. Overall, our findings indicate that wearing a sleeve is likely not to enhance, nor interfere with recovery within a 6-week period, more than 6 months following ACL reconstruction.

Clinical implications

There is an increasing global incidence of ACL injury and reconstruction, particularly in young athletes [3, 49,50,51]. Such injuries reflect significant costs to the individual and health care system, while also placing short-term burden on work- and family-related commitments [52, 53]. Decreased physical activity and increasing body weight following ACL injuries have been noted [54]. Thus, encouraging continued physical activity is required to combat long-term impairments, as well as re-injury. Fear of re-injury and loss of confidence of the knee is frequently reported following ACL reconstruction [41, 55, 56]. Such fear, while a rational response to this injury, may contribute to reluctance in undertaking physical activity and exercise [53, 54, 57]. Interventions are needed to enhance confidence. Graded exposure to functional exercise and sports- and work-specific skills as well as psychologically-informed approaches are used to enhance confidence following ACL injury [58,59,60]. It is possible that a knee sleeve could be used as an adjunct to such interventions with the aim of enhancing confidence [23, 27]. Based on our results, use of a knee sleeve during rehabilitation can be considered to immediately improve specific activities. However, self-reported knee function, hop distance and thigh muscle strength did not improve to a greater extent for the group wearing the knee sleeve compared to the Control Group at 6 weeks follow-up.

Data from this study thus does not support routine use of knee sleeves in individuals recovering from ACL reconstruction surgery. Further larger studies with longer duration use of sleeves would be required to further assess which type of patients would potentially benefit most from knee sleeves. Based on the results of our study and the current evidence, prescription of knee sleeve as an adjunct to rehabilitation and continued physical activity should be based on individual assessment and response to use of a knee sleeve.

Methodological considerations

A strength of this study was that we recruited participants with specific self-reported levels of functional limitation, defined by an IKDC-SKF score less than 80/100. While that eligibility criterion challenged our recruitment rate, the strategy enhanced external validity of our findings for ACL reconstruction with residual or persistent restrictions, more than 6 months following ACL reconstruction. Compliance with wearing the knee sleeve, and documenting use as well as physical activity relied on participants’ self-report. Use of pedometers, mobile physical activity apps and wearable technology may have given greater confidence in those results, however, those devices are also dependent on participants choosing to use them [61]. In this study, both groups used the same format for the diaries and were sent email reminders by a research team member.

This study was affected by the 6-week COVID-19 lockdown of 2020 in New Zealand, loosing 8 participants for the laboratory follow-up session. Despite continuing recruitment post-lockdown, we were unable to recruit sufficient participants to meet the planned sample size of 16 per group for the RCT within the funding period. Our results may thus reflect a Type 2 error for the 6-week effects of wearing a sleeve. Our sample size calculation was based primarily on the cross-over trial, and not the RCT, further adding towards risk of type II error rate for the latter. Finally, due to research staff changes during the course of the study, the researcher collecting data was not blinded to the group allocation for the RCT. Standard instructions were provided to the participants for the hop test and the muscle strength test. Hop test distance was measured by a research assistant blinded to the group allocation. Isokinetic peak torque was processed and extracted using the Biodex software, thus was not influenced by lack of blinding.

Conclusions

In a group of 34 participants with ACL reconstruction, single leg hop distance on the injured side improved immediately when wearing a knee sleeve compared to not wearing the sleeve. However, wearing the sleeve for 6 weeks for a at least 1 h per day did not lead to enhanced improvements in self-reported knee function, hop distance and thigh muscle strength compared to the control group who did not receive that sleeve.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ACL:

Anterior cruciate ligament.

BMI:

Body mass index.

IKDC-SKF:

International knee Documentation Classification Subjective Knee Form.

METs:

Metabolic equivalents.

RCT:

Randomised clinical trial.

References

  1. Rahardja R, Zhu M, Love H, Clatworthy MG, Monk AP, Young SW. Effect of graft choice on revision and contralateral anterior cruciate ligament reconstruction: Results from the New Zealand ACL registry. Am J Sports Med. 2019;48(1):63–9.

    PubMed  Article  Google Scholar 

  2. Sanders TL, Maradit Kremers H, Bryan AJ, Larson DR, Dahm DL, Levy BA, Stuart MJ, Krych AJ. Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. Am J Sports Med. 2016;44:1502–7.

    PubMed  Article  Google Scholar 

  3. Sutherland K, Clatworthy M, Fulcher M, Chang K, Young SW. Marked increase in the incidence of anterior cruciate ligament reconstructions in young females in New Zealand. ANZ J Surg. 2019;89(9):1151–5.

    PubMed  Article  Google Scholar 

  4. Janssen KW, Orchard JW, Driscoll TR, van Mechelen W. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports. 2012;22(4):495–501.

    CAS  PubMed  Article  Google Scholar 

  5. Granan LP, Forssblad M, Lind M, Engebretsen L. The Scandinavian ACL registries 2004–2007: baseline epidemiology. Acta Orthop. 2009;80(5):563–7.

    PubMed  PubMed Central  Article  Google Scholar 

  6. The New Zealand Anterior Cruciate Ligament Anual Report [http://nzoa.org.nz/new-zealand-acl-registry], 2020. Accessed 1 Dec 2020.

  7. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42(7):1567–73.

    PubMed  PubMed Central  Article  Google Scholar 

  8. Barenius B, Ponzer S, Shalabi A, Bujak R, Norlén L, Eriksson K. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year follow-up study of a randomized controlled trial. Am J Sports Med. 2014;42:1049–57.

    PubMed  Article  Google Scholar 

  9. Petersen W, Taheri P, Forkel P, Zantop T. Return to play following ACL reconstruction: a systematic review about strength deficits. Arch Orthop Trauma Surg. 2014;134(10):1417–28.

    PubMed  Article  Google Scholar 

  10. Kaur M, Ribeiro DC, Lamb P, Webster K, Sole G. Low knee-related quality of life and persistent physical asymmetries in participants up to 10 years post-ACL reconstruction – a cross-sectional study. Phys Ther Sport. 2021;48:35–42.

    PubMed  Article  Google Scholar 

  11. Kaur M, Ribeiro DC, Theis JC, Webster KE, Sole G. Movement patterns of the knee during gait following ACL reconstruction: a systematic review and meta-analysis. Sports Med. 2016;46(12):1869–95.

    PubMed  Article  Google Scholar 

  12. Bell DR, Pfeiffer KA, Cadmus-Bertram LA, Trigsted SM, Kelly A, Post EG, Hart JM, Cook DB, Dunn WR, Kuenze C. Objectively measured physical activity in patients after anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45(8):1893–900.

    PubMed  PubMed Central  Article  Google Scholar 

  13. Johnston PT, McClelland JA, Feller JA, Webster KE. Knee muscle strength after quadriceps tendon autograft anterior cruciate ligament reconstruction: systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2020. https://doi.org/10.1007/s00167-020-06311-y.

    Article  PubMed  Google Scholar 

  14. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE. Anterior cruciate ligament reconstruction autograft choice: Bone-tendon-bone versus hamstring: Does it really matter? A systematic review. Am J Sports Med. 2004;32(8):1986–95.

    PubMed  Article  Google Scholar 

  15. Magnussen RA, Verlage M, Flanigan DC, Kaeding CC, Spindler KP. Patient-reported outcomes and their predictors at minimum 10 years after anterior cruciate ligament reconstruction: a systematic review of prospectively collected data. Orthop J Sports Med. 2015;3(3):2325967115573706.

    PubMed  PubMed Central  Article  Google Scholar 

  16. Spindler KP, Huston LJ, Chagin KM, Kattan MW, Reinke EK, Amendola A, Andrish JT, Brophy RH, Cox CL, Dunn WR, et al. Ten-year outcomes and risk factors after anterior cruciate ligament reconstruction: A MOON Longitudinal Prospective Cohort Study. Am J Sports Med. 2018;46(4):815–25.

    PubMed  Article  Google Scholar 

  17. Filbay SR, Ackerman IN, Dhupelia S, Arden NK, Crossley KM. Quality of life in symptomatic individuals after anterior cruciate ligament reconstruction, with and without radiographic knee osteoarthritis. J Orthop Sports Phys Ther. 2018;48(5):398–408.

    PubMed  Article  Google Scholar 

  18. Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM. Health-Related quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2013;42:1247–55.

    PubMed  Article  Google Scholar 

  19. Ardern CL, Taylor NF, Feller JA, Webster KE. Fear of re-injury in people who have returned to sport following anterior cruciate ligament reconstruction surgery. J Sci Med Sport. 2012;15(6):488–95.

    PubMed  Article  Google Scholar 

  20. Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019;33(1):33–47.

    PubMed  PubMed Central  Article  Google Scholar 

  21. Yang X-g, Feng J-t, He X, Wang F, Hu Y-c. The effect of knee bracing on the knee function and stability following anterior cruciate ligament reconstruction: a systematic review and meta-analysis of randomized controlled trials. Orthop Traumatol. 2019;105(6):1107–14.

    Google Scholar 

  22. Bordes P, Laboute E, Bertolotti A, Dalmay JF, Puig P, Trouve P, Verhaegue E, Joseph PA, Dehail P, De Seze M. No beneficial effect of bracing after anterior cruciate ligament reconstruction in a cohort of 969 athletes followed in rehabilitation. Ann Phys Rehabil Med. 2017;60(4):230–6.

    CAS  PubMed  Article  Google Scholar 

  23. Kaur M, Ribeiro DC, Theis JC, Webster KE, Sole G. Individuals’ experiences of the consequences of anterior cruciate ligament reconstruction surgery. NZ J Physio. 2019;48:76–93.

    Google Scholar 

  24. Schween R, Gehring D, Gollhofer A. Immediate effects of an elastic knee sleeve on frontal plane gait biomechanics in knee osteoarthritis. PLoS One. 2015;10(1):e0115782.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  25. Mohd Sharif NA, Goh S-L, Usman J, Wan Safwani WKZ. Biomechanical and functional efficacy of knee sleeves: a literature review. Phys Ther Sport. 2017;28:44–52.

    PubMed  Article  Google Scholar 

  26. Van Tiggelen D, Coorevits P, Witvrouw E. The use of a neoprene knee sleeve to compensate the deficit in knee joint position sense caused by muscle fatigue. Scand J Med Sci Sports. 2008;18:62–6.

    PubMed  Article  Google Scholar 

  27. Birmingham TB, Bryant DM, Giffin JR, Litchfield RB, Kramer JF, Donner A, Fowler PJ. A randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. Am J Sports Med. 2008;36(4):648–55.

    PubMed  Article  Google Scholar 

  28. Schulz KF, Altman DG, Moher D, the CG. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Trials. 2010;11(1):32.

    PubMed  PubMed Central  Article  Google Scholar 

  29. Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD. Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med. 2001;29(5):600–13.

    CAS  PubMed  Article  Google Scholar 

  30. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43–9.

    Google Scholar 

  31. van BL Meer, Meuffels DE, Vissers MM, Bierma-Zeinstra SMA, Verhaar JAN, Terwee CB, Reijman M. Knee injury and osteoarthritis outcome score or international knee documentation committee subjective knee form: which questionnaire is most useful to monitor patients with an anterior cruciate ligament rupture in the short term? Arthroscopy. 2013;29(4):701–15.

    Article  Google Scholar 

  32. Lefevre N, Klouche S, Mirouse G, Herman S, Gerometta A, Bohu Y. Return to sport after primary and revision anterior cruciate ligament reconstruction: a prospective comparative study of 552 patients from the FAST Cohort. Am J Sports Med. 2017;45:34–41.

    PubMed  Article  Google Scholar 

  33. Gustavsson A, Neeter C, Thomee P, Silbernagel KG, Augustsson J, Thomee R, Karlsson J. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):778–88.

    PubMed  Article  Google Scholar 

  34. Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther. 2007;87(3):337–49.

    PubMed  Article  Google Scholar 

  35. Sole G, Hamren J, Milosavljevic S, Nicholson H, Sullivan SJ. Test-retest reliability of isokinetic knee extension and flexion. Arch Phys Med Rehabil. 2007;88(5):626–31.

    PubMed  Article  Google Scholar 

  36. Byrne NM, Hills AP, Hunter GR, Weinsier RL, Schutz Y. Metabolic equivalent: one size does not fit all. J Appl Physiol. 2005;99(3):1112–9.

    PubMed  Article  Google Scholar 

  37. Anderson AF, Irrgang JJ, Kocher MS, Mann BJ, Harrast JJ. The International Knee Documentation Committee Subjective Knee Evaluation Form: normative data. Am J Sports Med. 2006;34(1):128–35.

    PubMed  Article  Google Scholar 

  38. Muller B, Yabroudi MA, Lynch A, Lai C-L, van Dijk CN, Fu FH, Irrgang JJ. Defining thresholds for the Patient Acceptable Symptom State for the IKDC Subjective Knee Form and KOOS for patients who underwent acl reconstruction. The Am J Sports Med. 2016;44(11):2820–6.

    PubMed  Article  Google Scholar 

  39. Edwards PK, Ebert JR, Joss B, Ackland T, Annear P, Buelow J-U, Hewitt B. Patient characteristics and predictors of return to sport at 12 months after anterior cruciate ligament reconstruction: The importance of patient age and postoperative rehabilitation. Orthop J Sports Med. 2018;6(9):2325967118797575.

    PubMed  PubMed Central  Article  Google Scholar 

  40. Ebert JR, Webster KE, Edwards PK, Joss BK, D’Alessandro P, Janes G, Annear P. Current perspectives of Australian therapists on rehabilitation and return to sport after anterior cruciate ligament reconstruction: a survey. Phys Ther Sport. 2019;35:139–45.

    PubMed  Article  Google Scholar 

  41. Thomee R, Kaplan Y, Kvist J, Myklebust G, Risberg MA, Theisen D, Tsepis E, Werner S, Wondrasch B, Witvrouw E. Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19(11):1798–805.

    PubMed  Article  Google Scholar 

  42. Swearingen J, Lawrence E, Stevens J, Jackson C, Waggy C, Davis DS. Correlation of single leg vertical jump, single leg hop for distance, and single leg hop for time. Phys Ther Sport. 2011;12(4):194–8.

    PubMed  Article  Google Scholar 

  43. Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Contralateral limb strength deficits after anterior cruciate ligament reconstruction using a hamstring tendon graft. Clin Biomech. 2007;22(5):543–50.

    Article  Google Scholar 

  44. Erin HH, Joseph Z, Stephanie Di S, Michael JA, Lynn S-M. Preoperative Predictors for noncopers to pass return to sports criteria after ACL Reconstruction. J Appl Biomech. 2012;28(4):366–73.

    Article  Google Scholar 

  45. Goerger BM, Marshall SW, Beutler AI, Blackburn JT, Wilckens JH, Padua DA. Anterior cruciate ligament injury alters preinjury lower extremity biomechanics in the injured and uninjured leg: the JUMP-ACL study. Br J Sports Med. 2015;49(3):188–95.

    PubMed  Article  Google Scholar 

  46. Mirkov DM, Knezevic OM, Maffiuletti NA, Kadija M, Nedeljkovic A, Jaric S. Contralateral limb deficit after ACL-reconstruction: an analysis of early and late phase of rate of force development. J Sports Sci. 2017;35(5):435–40.

    PubMed  Article  Google Scholar 

  47. Collins A, Blackburn T, Olcott C, Jordan JM, Yu B, Weinhold P. A kinetic and kinematic analysis of the effect of stochastic resonance electrical stimulation and knee sleeve during gait in osteoarthritis of the knee. J Appl Biomech. 2014;30(1):104–12.

    PubMed  Article  Google Scholar 

  48. Hyo-Jeoung K, Dae-Sung P, Ju Ri J, Kwang-Ik J. The effect of silicone sleeve and taping on balance and strength in anterior cruciate ligament reconstruction patients. J Kor Phys Ther. 2014;26(3):147–55.

    Google Scholar 

  49. Zbrojkiewicz D, Vertullo C, Grayson JE. Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. Med J Australia. 2018;208(8):354–8.

    PubMed  Article  Google Scholar 

  50. Dodwell ER, LaMont LE, Green DW, Pan TJ, Marx RG, Lyman S. Twenty years of pediatric anterior cruciate ligament reconstruction in New York state. Am J Sports Med. 2014;42(3):675–80.

    PubMed  Article  Google Scholar 

  51. Abram SGF, Price AJ, Judge A, Beard DJ. Anterior cruciate ligament (ACL) reconstruction and meniscal repair rates have both increased in the past 20 years in England: hospital statistics from 1997 to 2017. Br J Sports Med. 2020;54(5):286–91.

    PubMed  Article  Google Scholar 

  52. Bahr R, Clarsen B, Ekstrand J. Why we should focus on the burden of injuries and illnesses, not just their incidence. Br J Sports Med. 2018;52(16):1018–21.

    PubMed  Article  Google Scholar 

  53. Scott S, Perry MA, Sole G. “Not always a straight path”: patients’ perspectives following anterior cruciate ligament rupture and reconstruction. Disabil Rehabil. 2018;40:2311–7.

    PubMed  Article  Google Scholar 

  54. de Oliveira FCL, Roy J-S, Pappas E. ACL injury, physical activity, and overweight/obesity: a vicious cycle? Knee Surg Sports Traumatol Arthrosc. 2019;28:667–9.

    PubMed  Article  Google Scholar 

  55. Webster KE, Nagelli CV, Hewett TE, Feller JA. Factors associated with psychological readiness to return to sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2018;46:1545–50.

    PubMed  PubMed Central  Article  Google Scholar 

  56. Ardern CL, Taylor NF, Feller JA, Webster KE. A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med. 2013;47:1120–6.

    PubMed  Article  Google Scholar 

  57. Filbay SR, Crossley KM, Ackerman IN. Activity preferences, lifestyle modifications and re-injury fears influence longer-term quality of life in people with knee symptoms following anterior cruciate ligament reconstruction: a qualitative study. J Physiother. 2016;62(10):103–10.

    PubMed  Article  Google Scholar 

  58. Ardern CL, Kvist J, Ardern C, Kvist J, Fältström A, Stålman A, O’Halloran P, Webster K, Taylor N. on behalf of the BTG: BAck iN the Game (BANG) – a smartphone application to help athletes return to sport following anterior cruciate ligament reconstruction: protocol for a multi-centre, randomised controlled trial. BMC Musculoskel Disord. 2020;21(1):523.

    Article  Google Scholar 

  59. Mahood C, Perry M, Gallagher P, Sole G. Chaos and confusion with confidence: Managing fear of Re-Injury after anterior cruciate ligament reconstruction. Phys Ther Sport. 2020;45:145–54.

    PubMed  Article  Google Scholar 

  60. Annear A, Sole G, Devan H. What are the current practices of sports physiotherapists in integrating psychological strategies during athletes’ return-to-play rehabilitation? Mixed methods systematic review. Phys Ther Sport. 2019;38:96–105.

    PubMed  Article  Google Scholar 

  61. Bunn JA, Navalta JW, Fountaine CJ, Reece JD. Current state of commercial wearable technology in physical activity monitoring 2015–2017. Int J Exerc Sci. 2018;11(7):503–15.

    PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We thank the Biostatistics Centre, Division of Health Sciences, University of Otago, Dunedin, for performing the statistical analyses of the outcomes of the trial. We also thank David Jackson, Anupa Pathak and Dr Mandeep Kaur for their assistance for data collection and processing.

Funding

A commercial company provided funding for the study. The Funder was not involved in participant recruitment, data collection, processing and analysis, and interpretation of results, and in no way influenced experimental procedures or report preparation. The funding covered the overheads for the Biomechanics laboratory, laboratory technician, administrative support, research assistant, contribution towards participant transport costs, and staff-related overheads.

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Authors and Affiliations

Authors

Contributions

GS and NH instigated this research project; GS, PL, TP, SK and NH contributed to the research design; GS provided necessary administrative support; GS and PN provided participant recruitment; GS and a colleague at the Biostatistics Centre, University of Otago contributed to the statistical methodology. GS, PL, TP, SK, PN and NH assisted with the initial construction and direction of the discussion, and developing the multiple iterations of the manuscript. All authors reviewed and provided constructive advice and critique to the editing process. All authors support the submission of this manuscript for peer review and publication. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Gisela Sole.

Ethics declarations

Ethics approval and consent to participate

Ethics approval was granted by the Health & Disability Ethics Committee, New Zealand, Reference 18/CEN/93, dated 5th June 2018, amended on 27th August 2019 and 4th October 2019. All procedures were performed in accordance to relevant guidelines. All participants provided written informed consent to participate.

Consent for publication

The authors have obtained the participants’ written informed consent for print and electronic publication of this research.

Competing interests

The Funder’s involvement was limited as described below under ‘Funding’. There are no patents, products in development or marketed products to declare.

The authors declare they have no competing interests.

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Supplementary Information

Additional file 1: Appendix 1.

Description and psychometric properties of outcome measures. Appendix 2. Reasons for exclusion from the study

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Sole, G., Lamb, P., Pataky, T. et al. Immediate and 6-week effects of wearing a knee sleeve following anterior cruciate ligament reconstruction: a cross-over laboratory and randomised clinical trial. BMC Musculoskelet Disord 22, 655 (2021). https://doi.org/10.1186/s12891-021-04540-x

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Keywords

  • Anterior cruciate ligament reconstruction
  • Knee sleeve
  • Patient reported outcome
  • Hop distance
  • Muscle strength