[The Physician and Sportsmedicine]

Bracing for Activity

Susan Wichmann and D.R. Martin

THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 9 - SEPTEMBER 96

A wide variety of braces is available in an ever-changing market for physicians treating athletes who are in rehabilitation and/or returning to competition. Though helpful and important, braces do not ensure against reinjury. To promote compliance and achieve successful rehabilitation, physicians must understand the nature of the patient's activity, how a given brace works, the anatomy and physiology of the joint, and the patient's expectations and concerns.

Not too long ago, physicians, trainers, physical therapists, and other healthcare professionals who treated athletes had limited choices for bracing injured joints for rehabilitation and competition. The sparse repertoire included taping, elastic bandages, and plaster casts.

But in recent years, a large market has sprung up around the sprained ankles and torn anterior cruciate ligaments (ACLs) of both competitive and "duffer" athletes. Brace manufacturers rapidly spin off new and sometimes costly brace designs and have the marketing clout to let the athletes and sports medicine communities know about them. "This market changes every year, maybe every half year," says John Henderson, DO, a family physician and director of primary care sports medicine at the Hughston Orthopaedic Clinic in Columbus, Georgia. "More people come up with more gadgets, some of which can help. So physicians have to know the science of the gadget and the biomechanics of the gadget. But they have to know even more about the person they are using this gadget on.

"When we put these things on people, we need to understand why we are doing this and what the consequences are. What's the potential for something else to go wrong?," says Henderson, who is an editorial board member of the physician and sportsmedicine. "It's a huge balancing act."

What Can Bracing Do?

To begin with, after injury, a brace is not a panacea. It does not take the place of good rehabilitation, says Jim Zachazewski, MS, PT, ATC, SCS, supervisor of outpatient services for the Department of Physical Therapy at Newton-Wellesley Hospital in Newton, Massachusetts. "The brace is a short-term, stop-gap assisting entity--quite literally, a crutch for the period soon after a injury," he says. "What you try to do is provide a device to aid the healing process and rehabilitation program, allowing the athlete to regain good strength, balance, proprioception, and reaction time. These critical factors are the hallmark of a good rehabilitation program."

The primary functions of braces include protection, support, compression, restriction of movement, and immobilization. They may improve proprioception and reduce swelling, says Sandra Lane, MD, a primary care sports medicine physician and director of sports medicine fellowship at SportsMedicine Grant in Columbus, Ohio. "Immediately after an injury, a brace can help reduce inflammation around the joint by providing joint stabilization and thereby decreasing swelling and pain," she says. "Braces that limit range of motion may be appropriate after a sprain to promote ligament healing and protect the joint once the athlete returns to play."

Knee braces--which run a gamut from simple sleeve braces to costly custom devices--can help treat conditions such as patellar subluxation, medial collateral ligament sprains, meniscus tears, ACL tears, kneecap pain ("runner's knee"), and patellar tendinitis.

Functional knee braces are used following injury, while prophylactic braces are designed to prevent injury. There is some evidence that functional braces can assist in protecting against injury in low-load, low-velocity, low-torque activities, Zachazewski says. Prophylactic braces may help decrease injuries for certain players in certain positions in contact sports such as football, he says; however the use of prophylactic braces is controversial. But for the high-velocity, higher-load, higher-torque activities such as jumping, pivoting, or cutting, or in certain contact situations, no brace can prevent an injury.

Lane explains that braces for ankles don't vary as widely by feature and cost as knee braces, but can play a positive role in treatment of Achilles tendon pain, ankle sprains, and instability following grade 2 ankle sprains. In jumping sports, Lane says the appropriate brace can also limit plantar flexion--an unstable, vulnerable position for an injured (or uninjured) ankle.

Wrist straps and splints are available for such hand or wrist conditions as tendinitis of the wrist or thumb, sprains, carpal tunnel syndrome, and scaphoid fractures. Jammed fingers or fingers with minor fracture can be protected with splints.

Shoulder slings and pads can provide light support and can improve proprioception, while shoulder harnesses keep the shoulder from abducting and externally rotating to prevent dislocation, says Barney Poole, MEd, PT, ATC, director of the Human Performance and Rehabilitation Center, Inc, in Atlanta. "The shoulder is pretty much a muscularly controlled joint. If those muscles are not functioning, there's not a whole lot you can do about holding the joint in place," he says. A football offensive lineman might be able to play in a shoulder brace after a recent shoulder injury because he doesn't need to lift his arms high. But a defensive back or quarterback with a recent dislocation--who must hold his arms high--is simply out of luck. A shoulder cannot be protected in such a playing situation, Poole says.

Braces that appear "high-tech" are not all created equal. A patient with a torn ACL or posterior cruciate ligament (PCL), for example, could be asking for trouble by using an off-the-shelf hinged knee brace, says Lane. "Hinged braces will not contain a knee that has a torn ACL or PCL," Lane says. "But sometimes people will get hold of them and think that they have enough to keep their knee from dislocating when they've got a torn cruciate ligament. You need a custom brace for that."

Weighing Bracing Options

The brace market changes rapidly, producing a variety of different types and models, in all price ranges, from the inexpensive elastic ankle and knee sleeves sold at drugstores to costly custom braces.

Knee. Hinged knee braces (also called functional or playing braces) are available both off the shelf and as custom-fit units (1). Clinicians prescribe these devices to treat ligamentous instability manifested by abnormal knee rotation (medial and lateral) or translation (valgus and varus, anterior and posterior) (2). Functional braces (figure 1a: not shown) can be worn as an athlete returns to training or competition. But they may be most beneficial for athletes who have moderate instability and are active in low-to-moderate-load sports. Functional knee braces do not guarantee against instability in sports that require cutting, pivoting, or other quick changes in direction (2).

Custom functional braces are very expensive--from $600 to more than $1,000--and must be fitted by an orthopedic technician who measures or takes a cast of the patient's knee. Lane says these braces allow flexion and extension of the knee while preventing rotation of the tibia and/or anterior translation of the tibia. The newer types are light (only 3 to 6 lb) and come in bright, attractive colors. A relatively new option is off-the-shelf functional braces that come in several sizes; these less expensive braces are designed to provide support for ACL-deficient athletes who do not require a high level of performance.

Rehabilitation (nonplaying) knee braces are off-the-shelf devices used for conservative treatment of ligament tears and for postoperative care of meniscal repairs and other operative knee procedures (1). These braces--also called post-operative braces--take two distinct forms:

  1. a straight immobilizer made of foam with two metal rods down the side that is secured with Velcro and prevents all motion, and
  2. a hinged brace that allows range of motion to be set by tightening a screw control.
"These are used immediately post-injury in an effort to put the joint at rest and help protect it, while allowing appropriate but limited motion," says Zachazewski.

For conditions that involve the patellofemoral joint, such as runner's knee, a pullover knee sleeve with various types of cutouts that are designed to support or stabilize the patella can be helpful (figure 1b: not shown). Patients who have jumper's knee benefit from a cutout sleeve with a half-circle buttress below the kneecap. A single strap with an air pocket pad can offer the same effect, and be cooler. For patella dislocation or subluxation, a patellar stabilizing brace that has a cutout sleeve and heavier buttressing is indicated.

Ankle. Ankle braces range from simple off-the-shelf models that provide light support to custom hinged models that help control significant ankle instability. "My favorite is the good old-fashioned canvas lace-up brace," says Lane. The brace stabilizes the ankle against medial and lateral motion (figure 2: not shown). "The important thing is that it limits plantar flexion and inversion, which is a position of instability for the ankle," she says. "If the foot is at a 90° angle, it's a lot harder to twist it."

A double-upright brace with plastic molded pieces allows dorsiflexion and plantar flexion but very little inversion or eversion, says Poole. Since most ankle injuries are inversion sprains, he believes that this kind of brace is just what's called for. Aircast (Aircast Inc, Summit, New Jersey) and similar braces incorporate an air pillow, gel pillow, or foam pillow that prevents inversion and eversion, but not plantar flexion or dorsiflexion. Some models, however, are not appropriate for playing, such as the midcalf Aircast Standard, says Poole. The smaller Aircast Sport can be worn during training and competition.

Upper extremity. A single strap brace is used for patients who have wrist tendinitis. Patients who have wrist sprains, tendinitis, or carpal tunnel syndrome can be treated with a cock-up wrist splint that leaves the thumb and fingers free. A thumb spica splint immobilizes the thumb when patients require treatment for thumb tendinitis.

For patients who jam their fingertips and damage the extensor tendon at the top of the finger, a dorsal finger splint worn over the distal interphalangeal joint keeps the joint in extension as the tendon heals, but allows finger function because the first knuckle can still bend.

A shoulder harness would theoretically diminish shoulder instability but could interfere with the athlete's ability to perform, Henderson says. To catch a pass or block a punt a player might learn to bend his or her trunk sideways to raise the braced shoulder and arm. "So now, you're going to trade shoulder instability for back strain," he says.

Prescribing Tips

"Each sports medicine specialist should become familiar with the properties, fitting, and limitations of a few braces, so a special personal 'feel' about their efficacy may be developed," writes David C. Reid, BPT, MD, in the book Sports Injury Assessment and Rehabilitation (3). "The literature should be followed carefully for new developments. Degree of [joint] prominence and brace contact area, as well as comfort, fit and stability, tendency for slippage, cost, and range of motion permitted, are factors that should enter into the decision to supply a particular brace."

Poole, who regularly gives a seminar on braces at the annual American Academy of Family Physicians meeting, recommends that the physician always be able to provide patients with a choice of braces, but not too big a choice. "You need to have a couple of braces that you know are comfortable, even if it means doing an empathy experiment and actually wearing them yourself," he says. If a brace isn't comfortable, the athlete won't wear it, defeating any benefit (2). Likewise, if it doesn't fit properly, it's equally useless and could contribute to other injuries.

Physicians should also be aware of the constraints of patients' sports, says Henderson. For example, football rules should be understood, as well as the requirements of various positions. "This is all analogous to what we do in workers' comp cases, where you have to know what a person does on the assembly line to keep them functional," he says. "Otherwise, you need to modify their work, which, for a linebacker, might be switching from outside to inside."

It's also important to know the functional anatomy of the relevant joint and the peculiarities of a given patient population. For example, Henderson says if a physician is treating masters athletes--who have less padding around their joints and more superficial neurovascular bundles--he or she should be aware of possible compression from brace use.

When an athlete has an acute ankle injury and wants a quick return to activity, the physician should provide, whenever possible, a hybrid brace that's appropriate for both rehabilitation and playing. For example, Poole says substituting the smaller Aircast Sport for the Aircast Standard may make it unnecessary to buy two braces. Some functional knee braces that physicians prescribe during initial rehabilitation to restrict active range of motion of the knee can also be used as playing braces.

If a knee brace has been effective, but the patient reports that it's no longer providing good support, a little detective work may be in order. The patient may have developed poor brace application habits, or the brace may need adjustment or repair. A patient who has an ACL-deficient knee may also have developed a meniscal lesion, chondral flap, or a loose body, or may have developed quadriceps and hamstring weakness that requires an ongoing strengthening program (3).

Physicians should be able to fit the following simple braces in their offices: ankle braces, simple knee sleeves, off-the-shelf knee braces, and wrist and elbow sleeves and braces (2). Custom molded braces for the knee and some complex shoulder orthoses, however, need to be fitted by an expert, either the brace salesperson or a certified orthotist. "Basically, the closer to the skin the brace fits, the better," says Poole. Ideally, the brace should not bind the joint, it should allow as much motion as desired by the physician, and it should not rub up and down against the skin, he says. Skin breakdown and other problems can develop if the hinge is not at the joint line. "There should not be much space between the brace and the skin. The best fit is snug, but not restricting of the circulation," says Poole.

Initially, the patient wears the brace 24 hours a day, progressing to just during activity, practice, and games, says Poole. During the off season, the patient should complete the rehabilitation process--increasing strength and endurance--without the brace, as much as possible, he says.

Henderson believes that physicians must be sensitive to the financial ability of a patient who needs a brace--particularly a younger athlete in a family on a tight budget. "If I write him a prescription for a certain brace that costs several hundred dollars, I know that family won't have Christmas this year or they might skip a car payment," he says. "Patients are so trusting of people in healthcare that they'll think, 'Gee, if Dr Henderson said I should get that brace, then I better get it, no matter what.' Well, was that the right thing for me to do?"

Communicating with an athlete's coach is important, because they decide whether or not to play that person. What effect will brace use have on his or her performance? Might it be better for the coach to use someone less experienced but in better shape, and give the injured athlete more time to rehabilitate?

Prescribing the right brace requires more than just proper sizing, says Poole: The physician has to fit the brace based on the patient's activity and preferences. "You have to get them something they're going to like and use," he says. Many factors influence patient compliance, such as effectiveness, attractiveness, and color. "If they're going to put it in a drawer, you've wasted your patients' money and the insurance company's money--and you've put your patient at risk," he says.

Physicians also need to evaluate the patient's feelings about wearing the brace. For some, a brace is a sign of failure; for others, it's a badge of athletic accomplishment. "The brace is an inanimate thing made of textile and plastics, but it's going to go on a human being," says Henderson. "If I just look at the biologic and the mechanical nature of the bracing prescription, I've missed two-thirds of the boat."

References

  1. Jepson KK: The use of orthoses for athletes, in Birrer RB (ed): Sports Medicine for the Primary Care Physician. Boca Raton, Florida, CRC Press, 1994, pp 285-295
  2. Zachazewski JE, Geissler G: When to prescribe a knee brace. Phys Sportsmed 1992;20(11):91-99
  3. Reid DC: Knee ligament injuries: treatment, in Reid DC: Sports Injury Assessment and Rehabilitation. New York City, Churchill Livingstone, 1992, pp 541-546

Susan Wichmann and D.R. Martin are freelance writers in Minneapolis.


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