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[CLINICAL TECHNIQUES]

Using Patellofemoral Braces for Anterior Knee Pain

Scott A. Paluska, MD; Douglas B. McKeag, MD, MS

Department Editor: William O. Roberts, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 8 - AUGUST 1999


Disorders of the patellofemoral joint are common in recreational and competitive athletes. The pathophysiology of these disorders is unclear but may be related to malalignment of the patella and femoral trochlea, which may produce the characteristic anterior knee symptoms (1). Diagnosing and treating patellofemoral pain syndrome is challenging but important, since patellofemoral abnormalities can result in substantial discomfort and disability.

One treatment measure that many patients find helpful for anterior knee pain is the simple-to-fit, inexpensive patellofemoral knee brace (PFB). These braces are best used as an adjunct to other therapies.

Benefits and Uses

PFBs were designed to minimize lateral patellar subluxation and dislocation, improve patellofemoral tracking, and decrease anterior knee pain (2). They are also intended to provide proprioceptive feedback and warm the patellofemoral joint. PFB manufacturers have made many claims about the efficacy and benefits of their braces, but most assertions have not been supported by scientific investigation or analysis (3).

As with other types of knee braces, however, patients who have worn PFBs report benefits that exceed the objective effects noted by researchers (3,4). While PFBs do not appear to alter underlying biomechanical dysfunction, they provide a static restraint that (in most cases) applies a medially directed force to the lateral patella, thereby decreasing abnormal patellofemoral tracking. The sleeve itself helps compress the tissues and limit excessive patellar movement.

PFBs are often used with other therapies for patellar subluxation or dislocation. They have also been advocated for treating Osgood-Schlatter disease, patellar chondromalacia, patellar tendinitis, and postoperative effusion (1). PFBs are contraindicated for an unstable knee that requires surgical management and for disorders unrelated to the patellofemoral joint.

Design and Selection

The principal component of a typical PFB (figure 1: not shown) is an elastic sleeve, often of neoprene, that affords warmth, compression, and minimal stabilization of soft-tissue restraints to patellar movement. The sleeve's elasticity helps keep the brace in place. Other components include one or more movable straps (often called "counterbalancing" straps since they counter pathologic lateral forces) that limit brace migration and allow adjustable compression around the calf and thigh; a patellar opening that holds the patella in a central position during knee flexion and extension; a buttress—of felt, gel, or an inflatable air pocket, often adjustable or removable—that restricts displacement of the patella; and, on some models, hinges that may increase the medial and lateral stability of the knee during vigorous activities.

Of the several PFB models available, most use a combination of neoprene, nylon brace covering, padding around the patellar cutout and in the buttresses, and Velcro straps. No particular materials or components are clearly better than others.

Some commonly used PFBs are listed in table 1. These and others can be obtained from local medical supply stores, directly from the manufacturer, or through brace distributors on the World Wide Web. Before purchasing a brace, it is advisable to compare different models and sizes at a local supplier and to contact several suppliers regarding cost, since actual and list prices can be substantially different.


Table 1. Commonly Used Patellofemoral Knee Braces, Manufacturers, and Costs

Brace Name Company Phone (800) Approximate Cost

Bledsoe Sport Max Bledsoe Brace System, Grand Prairie, Texas 527-3666 $55
Body Flex Gel Buttress Ortho-Care, Raytown, Missouri 821-1303 $34
Lateral J Buttress Support Smith & Nephew, Vista, California 336-6569 $29
McDavid Deluxe Knee Support McDavid Guard, Inc, Chicago 237-8254 $26
Palumbo Patella Tracker Palumbo Orthopaedic, Vienna, Virginia 292-7223 $39

Fitting

Custom PFBs are uncommon because most patients can be fitted with an off-the-shelf version. The brace size can be determined by measuring the circumference of the knee either at midpatella or 3 to 4 in. above and below the joint line of the affected knee, depending on the manufacturer's instructions. A properly sized PFB will compress the patellofemoral joint without restricting knee range of motion.

Once the proper size is chosen, align the hinges, if present, with the femoral condyles and secure the counterbalancing straps snugly around the patient's calf and thigh. Optionally, wide athletic tape can be applied to the top and bottom of the brace and the adjoining skin to discourage migration; this placement also allows adjustment of the straps and brace during prolonged athletic activity.

If the PFB has a movable counterbalancing strap, place it proximal to the patella for most patients and distal to the patella for those who have infrapatellar tendinitis. Place the buttress, if adjustable, lateral to the patella in those who have lateral patellar instability and medial to the patella in those who have the much less common medial patellar instability.

Therapeutic Adjunct

Though PFBs do not eliminate the underlying causes of anterior knee disorders (3,5), they are useful adjuncts to therapy. They are most effective when combined with directed stretching and strengthening of the quadriceps and hamstring muscles. In addition, biomechanical dysfunction of the hip, foot, or ankle should be addressed through the prescription of orthoses or other modalities. Lifestyle modifications and improved sports techniques may also help reduce symptoms.

References

  1. Cherf J, Paulos LE: Bracing for patellar instability. Clin Sports Med 1990;9(4):813-821
  2. Arroll B, Ellis-Pegler E, Edwards A, et al: Patellofemoral pain syndrome: a critical review of the clinical trials on nonoperative therapy. Am J Sports Med 1997;25(2):207-212
  3. Greenwald AE, Bagley AM, France EP, et al: A biomechanical and clinical evaluation of a patellofemoral knee brace. Clin Orthop 1996;324(Mar):187-195
  4. Shellock FG, Mink JH, Deutsch AL, et al: Effect of a newly designed patellar realignment brace on patellofemoral relationships. Med Sci Sports Exerc 1995;27(4):469-472
  5. Papagelopoulos PJ, Sim FH: Patellofemoral pain syndrome: diagnosis and management. Orthopedics 1997;20(2):148-157

Dr Paluska is a fellow in primary care sports medicine at the University of Pittsburgh Medical Center. Dr McKeag is the Arthur J. Rooney chair of sports medicine, a professor of family medicine and orthopedics, and the director of primary care sports medicine at the University of Pittsburgh. Dr Roberts is a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota.


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