By Melissa Klamm, ATC
Every year, roughly seven million high school students play sports. Nearly 40-60% of football players, 40-46% or wrestlers, and 31-37% of basketball players suffer an injury while participating in their respective sports. Many sports such as football require certain protective equipment to prevent injuries incurred from full body contact. However, athletic braces are optional equipment that may be useful for acute and chronic injuries and even prevention of injuries. Each sport has specific rules regarding what is allowed to be worn during a game. For example, football requires any metal hinges or plates to be covered with foam and tape to prevent injury to the player wearing the brace and others he may encounter.
Athletes use knee and ankle braces everyday to prevent initial or repeat injury, but is their supposed function supported by current research? The most common knee and ankle injuries treated and prevented by bracing include patellofemoral pain syndrome (PFPS), patella subluxation (pop in and out), medial collateral ligament (MCL) sprain, anterior cruciate ligament (ACL) sprain, and inversion ankle sprain. There are various brands and models for each condition.
Patellofemoral pain syndrome (PFPS) develops gradually with diffuse pain around the “kneecap” or patella and is usually prompted by overuse of the joint with such activities as stairs, running, cycling, or prolonged sitting. Malalignment of the patella can lead to abnormal tracking, which can cause stress on the patella, and pinching of the surrounding soft tissue. Lack of balanced muscle control can be another cause of such pain. Patella subluxation, kneecap popping in and out of place, is another condition triggered by trauma, malalignment, or imbalance of quadriceps muscles. Specific taping techniques exist, but the tape loosens and becomes ineffective within five minutes of vigorous exercise. A brace with a C or J shaped buttress that surrounds the inside border of the patella can be used to treat and prevent both conditions. These braces are said to improve tracking and maintain proper alignment in order to prevent irritation of the surrounding tissues and provide added support. The current research on these braces is conflicting. One research study found a significant reduction of pain in the braced group. This reduction may be due to improved proprioception or body awareness. There is currently inadequate evidence to either support or discourage the utilization of patellar bracing. A therapeutic trial may be advisable because the braces are usually inexpensive and no harmful side effects have been found.
Many high school, college, and professional football teams require linemen, linebackers, and tight ends to wear preventative knee braces to avoid MCL sprains. These braces are constructed with metal or hard plastic hinges on either side of the knee joint. The MCL is usually sprained when the knee takes a blow to the outside, which places tension on the inside of the knee joint where the MCL lies. A research study involving 987 division I NCAA football players supported the theory that these types of braces decrease the frequency of injury. The braces decreased the tension on the MCL by 20-30% to prevent sprains and tears. The main negatives include slippage, energy expenditure, and loss of speed. Slippage can happen when the brace does not have a good, tight fit. If the brace is not fitted properly, it may slip and prevent the brace from being effective. Another drawback is increased energy expenditure. According to the American Journal of Sports Medicine, the added weight of the brace has been shown to increase oxygen consumption, blood lactate levels, and therefore energy expenditure. These factors could lead to earlier fatigue versus an athlete who is not braced. Decreased speed is another issue mentioned with brace use. The presence of the brace may slow the straightaway sprint speed; however, this concern was only found in one study so may not be a major concern. Overall, a bilateral hinge brace may be beneficial for the prevention of MCL injuries, especially for the football positions of linemen, linebackers, and tight ends. The brace has also been used with other high contact sports such as rugby and soccer as long as the hinges are covered for the protection of everyone on the field.
The other major knee condition where braces are used to prevent recurrence of injury is after an ACL tear and reconstruction. Many doctors choose to place athletes in an ACL brace before returning to normal competitive levels. The ACL is the ligament within the knee joint that prevents forward movement of the tibia on the femur; therefore, the brace is made to protect against this. According to Ramsey et al, consistent reductions in forward translation were not found when testing the ACL knee brace. Also, other studies reported failure of such braces when high loads were met or applied in an unpredictable way. The braces do not provide full protection from recurrence of injury, but patients wearing the brace reported perceived improved performance. The ACL brace does reduce irregular movement under low loads but not under the high forces related to certain athletics. Doctors and patients should guard against a false security from the brace.
Ankle inversion sprains are a very common acute musculoskeletal injury incurred while playing sports. Ankle braces perform better than tape alone because tape can lose its tightness and effectiveness within twenty minutes of vigorous exercise. External ankle support such as a brace improves balance control and joint feedback, a vital part of reducing recurrent ankle sprains. There are two types of ankle braces: semi-rigid and soft lace-up. Elastic sleeves are not included because they help reduce swelling but do not provide stability. Semi-rigid braces are constructed of plastic contoured lateral stirrups lined with foam pads for support of the ankle joint. The semi-rigid brace restricts ankle inversion better than lace-up braces during high-risk sports like soccer and basketball. One study suggests patients with moderate to severe sprains should wear the brace for at least six months. The use of ankle braces significantly reduces the frequency of ankle injuries especially for athletes’ with a history of previous ankle sprains. Some athletes believe braces restrict performance; however, no adverse effect on jumping or sprinting was found during several research studies. Ankle braces are a good choice for prevention of initial and recurrent injury especially in high risk sports.
Overall, the negatives of bracing seem to be outweighed by the positives. The various knee braces’ functions are still questionable because research has not been able to conclusively determine the preventative effects. However, the semi-rigid ankle brace seems to be the best bet for injury prevention. Never replace proper rehabilitation and strengthening with a brace just to return to sports prematurely. When using a brace, the key to effectiveness is consistency of use and proper fit. When determining the need for a brace, remember to always consult your physician, physical therapist, or certified athletic trainer to help choose the best brace.
Image from: www.balegoonline.org
Melissa Klamm, ATC provides sports medicine services to Eastern High School in Louisville, KY as a part of the Kentucky Orthopedic Rehab Team (KORT). KORT provides athletic trainers to many Kentuckiana high schools and colleges.