Brace Use in
Sports
Medicine
DHARMPAL VANSADIA, DO, MPH
LATA 2017
No Financial Disclosures
Goals & Focus

ATs,

MCL

ACL

PCL

Ankle Sprains
Epidemiology

~ 250,000 new ACL injuries

~ 200,000 ACL reconstructions

85% of reconstructions are braced – AOSSM

Unknown frequency of MCL, PCL, elbow injuries

Affects outcome


Return to play, careers

Patient satisfaction & confidence

Surgeon reputation
Multi-billion $$ industry

Private practice
AAOS

Position Statement 1997

Does not endorse prophylactic bracing for any
sports

Retired the statement in 2008

Currently, no position
Myths of Bracing

Brace use is associated with increase in frequency
or severity of injury

Brace use can prevents catastrophic knee injuries

Brace decreases speed & agility

All braces are equal
Advantages of Brace Use

Protect joints & tissues

Force absorption & distribution

Increasing force threshold to tissue injury

Protect graft & soft tissue after reconstruction

Decreased gait & kinematic asymmetry in
reconstructed joints

Improves confidence by enhancing sensorimotor
feedback during high level activities

Early return to sports while injured joints & tissues
are not healed
Dangers of Bracing

Through “stress shielding” prevents activation of
neuromuscular control system


Atrophy
Brace-induced maladaptive lower extremity
kinematic compensations & ROM restrictions

Reduction in knee extension velocity

Slow straight-ahead sprint speed & agility

Cause early fatigue

Increase muscular relaxation pressure, energy
expenditure, blood lactate level, O2 consumption
MCL Injuries & Bracing
MCL Bracing Controversy

Does using a brace prevent MCL injuries?

Should we prophylactically brace athletes?

What position are most vulnerable?
Protection Against Valgus
Moment

MCL experiences immediate stress on valgus
loading at lateral joint line

The MCL, the ACL, and the PCL provide restraint

Cadaveric Studies

Off-the-shelf functional braces


20% to 30% higher resistance
Custom braces

40% to 60% higher resistance
Big 10 Conference Study


3yr prospective study
55,722 knee exposure

Every practice & game

51% wore brace

80 MCL injuries

34 in braced

46 in unbraced knee
Big 10 Conference Study
Big 10 Conference Study

Type of Session – Game vs. practice

Position – lineman > linebacker > skills

String – starter vs. bench

Highly correlated with MCL injury

Compared to knee brace used
West Point Study

West Point cadet, randomized, control study

Highly controlled, same brace, compliance, and
previous injuries excluded

71 injuries in 1396 cadets, 2.46/1000 exposure

Control group 3.4/1000 exposure

Braced group 1.5/1000 exposure


Higher % of injuries were less severe
Difference most significant for MCL injury in
defensive players
MCL Practice Guidelines

Bracing does prevent MCL injuries

Routine brace should be offered only to select
population


Linemen > Linebackers
Player can expect

Increased fatigue & energy expenditure

Skill position players likely notice decrease in speed


Better protection against multi-ligamentous injuries
Prophylactic bracing on cases by cases basis
after discussion with player
ACL Injuries & Bracing
Debate ACL & Bracing

Should we brace native uninjured ACL?

Should we brace reconstructed ACL?

At immediate post operative

During rehab

Return to play
Why brace ACL
Reconstructions?

63% of orthopedic surgeons recommended
functional brace

Rx 9-12 months after return to play
Minimizes graft stress by decreasing translational,
rotatory, and valgus loads
 Safer progression of PT during the unknown period



Protect graft incase of an accident/excessive force

Remind patient for recent sx – “hold them back”
Improved confidence – decreasing fear avoidance
and kinesiophobia

Tjong et al., Fear – most encountered factor for sports
cessation
Bracing Native ACL

No evidence that routine native knee bracing
prevents ACL injuries

Neuromuscular training, sports specific training

Contralateral knee after reconstruction
Nebulung, et al.,
Arthroscopy 2005

19 Olympic athletes from East Germany

1963-1965 ACL injuries

Non-op tx, return to sports 6-14 weeks

1975 @ 10yr

1985 @ 20yr

2000 @ 35yr
•
1975 @ 10yr

15/19 (79%) had menisectomies

68% medial

37% lateral

1985 @ 20yr

18/19 (95%) had menisectomies

19/19 (100%) symptomatic knees

18/19 (95%) received arthroscopies

68% had grade 4 lesion

2000 @ 35-37yr

10/17 had TKA (60%)
 Lifetime

risk in general population is 10%
No athlete was able to return to their
pre-injury level
1964 Tokyo Olympics
 1-4yr stopped sports due to knee issues
 100% had pain, instability, swelling & loss
of motion

What if we reconstruct
acl?
Immediate Post-Op?
Return To Sports?

Lowe, et al., JAAOS 2017

14 Level II studies ~1300 patients

1 Level III

Kinematics

Strength

Function

Proprioception

Clinical Outcomes

Kinematics

6/15 studies

All studies found improvement in arthro-kinematics

Decrease in AP translation

Decrease in tibial rotation

Increase in peak knee abduction moment

Improvement in varus/valgus symmetry

Contrasting evidence

Functional

12/15 studies reviews function

Lachman, ROM, knee stability, single-leg hop
testing & isokinetic strength

All studies showed no difference between
bracing & non-bracing in any functional
outcomes


Proprioception

3/15 studies

No difference
Clinical Outcomes

Most studies

IKDC

Tegner

CKIOOS

VAS

No difference

Steadman, et al., AJSM, 2006

Prospective study, 820 recreational skiers

At 2yrs 61 ACL re-tears

10 in braced

52 in non-braced

Non-braced skiers at 2.74-fold risk of ACL tear

Caution!
Functional Brace For ACL

Improves knee joint kinematics

Gives greater control over rotational &
translational stress as knee progresses to intense
multiplaer motion

Increase patient confidence

No significant increase in proprioceptive
capacity—possible increase afferent sensation
contributes to patient confidence
ACL Brace Practice
Guidelines

Brace all ACL injuries during cutting & contact
sports when treated non-operatively

Brace isolated ACL reconstructions immediate
post-op


2 weeks locked for gait (soft tissue, swelling,
arthrofibrosis)

4 weeks unlocked (meniscal repair, etc)
Functional bracing for return to sports is
inconclusive

Brace soft tissue grafts (up to 1 yr)

Brace allografts (up to 2 yrs)

Literature does support functional brace for skiers!
PCL & Bracing
PCL Bracing

Uncommon Injuries

Frequency unknown (3-37% of acute knee injuries)

Most treated non-operatively


Intraarticular but extra synovial ligament


Great outcomes in isolated PCL injuries
Grade I-II healing potential in reduced joint
LaPrade et al., 1967-2011 - 8 studies about PCL
bracing
Historic PCL Bracing

Until recently

No brace on market that biomechanically
evaluated and validated for either non-op or post
op bracing

Braces were modified ACL bracing at prevented AP
plane motion
PCL Bracing Debate

Dynamic structure

Length and tension are variable throughout the
ROM -- “tension spring”

Proper treatment requires restoration of PCL to its
anatomic length and avoiding high flexion angles

Non-anatomic healing leads to destruction of PFJ
Advancing Bracing
Technology

“Dynamic Braces”

Anterior-directed force

Prevents posterior sag sign

Prohibits high flexion angles

Restores native joint position & kinematics

Prospective study, PCL-Jack Brace

21 patient with grade II PCL injury

MR @ 6 month show PCL healed

2yr follow-up

Cadaveric study

Measuring peak force and pressure in PFJ

PCL deficient & PCL deficient + brace

PCL/PLC deficient & PCL/PLC deficient + brace
PCL Brace Practice
Guidelines

Brace all PCL treated non-operatively

Dynamic brace is preferable to traditional PCL
braces

Brace for 3-4 month

Avoid flexion angles greater than 90° for 6 weeks

Brace reconstructed PCL

Avoid graft elongation

6 weeks
Ankle Sprain & Bracing

195 patient
Ankle Sprains Brace
Practice Guidelines



Brace acute ankle sprains

Brace prevents ankle inversion

2-6 weeks for stability

Taping = lace-up = semi-rigid
No bracing for return to sports after ankle sprain

No evidence that this prevents future injuries

Increase risk of knee injuries (inc knee IR)
Brace chronic ankle instability

Cutting sports activity

Increase risk of knee injuries

Refer for surgical intervention
Myths of Bracing

Brace use is associated with increase in frequency
or severity of injury - False

Brace use can prevents catastrophic knee injuries
– Probably True

Brace decreases speed & agility - True

All braces are equal – False
Questions?
THANK YOU!