Brace Yourself

Look in any medical supply catalog or down the aisles of the local pharmacy or sporting goods store and you will see dozens of different braces. Presumably, these products will allow you to function better with less pain. Braces are available for everything from your big toe to your neck and everything in between. In a series of articles, we will investigate the pros and cons of using braces for a few key areas including the lower back, knees and ankles. We will start with a brief description of the rationale for the use of braces in general.

First and foremost, braces are used to support soft tissues like muscles and ligaments. The construction of most braces uses neoprene (a stretchy rubber material) that can also act to keep local heat in the area. Neoprene braces are generally stretched to fit the desired area, which also provides compression. Compressive force to a joint can be of benefit for the reduction and prevention of localized swelling. Compression of a large muscle group (like the quadriceps on the front of the thigh) can actually help the muscle function slightly more efficiently. When a muscle contracts, or shortens, its job is to bring the bones closer together for movement. However, when it contracts a muscle also expands out to the side or widens. When mild compression is provided to the muscle, the brace gives the muscle something to push against for improved efficiency. This is also the rationale for athletes wearing compression shorts during sprinting activities like football and track and field. The limitations of these braces are that they can sometimes be hard to fit to some individuals. These braces are usually made in pre-fabricated styles and sizes. People who use these braces can not assume that the brace will provide significant support to joints and bones.

Braces are also used to provide skeletal support. This means that the brace helps keep two or more adjacent bones properly lined up. These types of braces tend to be made of nylon straps surrounding a hard material. Examples of these braces include knee braces to prevent ligament damage and wrist braces worn after a wrist fracture. Braces that serve this function usually need to incorporate hinges if they are designed to allow movement of a joint. These braces can be custom made with high-tech casting and molding methods or made as off-the-shelf pre-fabrications. The more of the brace that is made of hard materials (plastic, carbon fiber or other material), the greater the likelihood that the brace is custom-made.

One of the chief limitations of these braces, is that despite being custom-made, they are not entirely effective in their job of holding two bones in alignment. The reason for this seems to be due to the soft tissue movement that occurs. The brace is made to fit the outside of the body. Between the brace and the bones that are the target of the limitation lies skin, subcutaneous fat and muscles. All of these soft tissue layers allow the brace some “give” and movement. This limits the effects of the brace on the bones underneath the soft tissue layers. Other limitations of these braces can be the cost and the bulkiness of the brace itself while participating in desired activities. It would seem somewhat obvious that the more labor intensive and custom a brace is, the more expensive it is likely to be.

The descriptions of braces above are typical of the types of braces that individuals with common orthopedic injuries may be inclined to investigate. However, there is another function of orthopedic braces that exists for those with limited function. For those individuals with serious orthopedic dysfunctions that come with diagnoses like cerebral palsy or other neurological deficits, braces can play a crucial role in allowing the person to perform basic functions. The discussions in the specific articles on knee, ankle and lumbar braces will not focus on braces that are needed for body or limb support due to neurological or motor control deficits.

Ankle Braces and Tape

In the world of athletics, it is common for athletes to get their ankles taped up by their team’s athletic trainer. Young athletes see professionals tape their ankles and their perception is that they should do the same thing. However, most quickly realize that taping their ankles is hard, ineffective and eventually expensive. The next logical step would be to wear an ankle brace. After all, braces do the same thing as tape, right? The real question is not whether wearing an ankle brace is as effective as taping, but rather whether either should be done for young athletes as a preventative measure.

Using an ankle brace as a preventative measure has not been shown to lower rates of ankle injuries to a significant degree [Source: Verhagen]. This is probably because the number one risk factor for a sprained ankle is a previous injury to the ankle. Basically, if a person sprains an ankle once they are more likely to sprain it again later. Braces and taping are effective in preventing subsequent injuries after the first one. What is not known is whether taping or bracing will decrease the severity of a first ankle injury. This apparent discrepancy is likely due to the structures injured in an ankle sprain. The ligaments of the ankle are very effective in maintaining the stability of the foot and ankle. The ligaments get help from the muscles and tendons that work hard to keep the foot out of a position that might lead to an injury. The most common way ankle ligaments are injured is by “rolling the ankle” onto the outside of the foot. This can occur from stepping off a curb, stepping on the foot of another athlete, walking on uneven ground or planting and changing direction while running. If the ankle ligaments are injured seriously enough they heal with a decreased ability to keep the ankle stable, called ligamentous laxity. With less support from the ligaments, the ankle needs help. The muscles and tendons can help to some degree, but taping and bracing seems to help as well.

If taping or bracing does not help with preventing injuries the first time but does in preventing recurrent injury, the conclusion is that those who should use taping or bracing are those who have sustained a previous injury. There is some balance training that can be performed following an ankle injury to improve muscular control. However, most athletes would benefit from wearing an ankle brace for up to one year after the initial injury if ligamentous laxity has resulted. If the ankle maintains its ligament stability, there is no need for long-term bracing or taping.

Research comparing bracing and taping show that they have nearly the same level of effectiveness. This assumes that the taping technique is performed properly. To ensure proper support as well as to improve time and cost effectiveness, bracing is likely the best choice for those who do not have time or a trained person around to tape their ankle [Source: Mickel, Olmsted].

As with lumbar and knee braces, there is a fair amount of variety in ankle braces. Two primary types are the stirrup style and the lace-up style. Stirrup braces tend to be good at preventing pure sideways movement of the ankle. This style does not tend to be as effective for limiting multi-plane movement like sideways movement combined with twisting of the forefoot. The stirrup brace can be useful for athletes like volleyball players who are at risk of stepping on another player’s foot. Lace-up braces have the added ability to resist the twisting as well as the pure sideways movement. These braces are slightly more versatile and can be used for athletes who participate in sports like basketball, baseball, football or soccer where cutting and twisting are likely to occur.

Brace quality and prices can vary but not significantly. The highest quality braces generally retail for about $50 each while some braces can be purchased for as little as $20. Neoprene slip-on braces can be purchased for less but do not provide ligamentous support, only joint compression. If you have questions about what brace is right for you, consult your medical professional. Certified athletic trainers, physical therapists or podiatrists can assist you in making the most beneficial choice.

Knee Braces

When watching a professional football game, you will see many players wearing knee braces. These are generally worn to protect the knees when they are hit from the side during the vast number of expected and unexpected collisions. In the past, knee braces were commonly worn throughout the rehabilitation process after surgery. Braces are also commonly worn in an attempt to reduce anterior knee pain, pain on the front of the knee or related to the kneecap. As with other types of braces, there is a wide range of types and costs. Generally speaking, the more custom a brace is and the harder material from which it is made, the greater the cost will be. As with all types of bracing, the question to ask is whether or not they are effective.

We must first explore the common uses. A common need for a knee brace is to prevent knee injuries. The data and clinical experience available indicates that using a knee brace with metal hinges on the sides may have a slight effect in reducing medial-sided (inside part of the knee) ligament injuries in college football players. The reduction is very small and not considered significant by medical research standards. These can not protect the interior ligaments (ACL or the PCL). Additionally, the player's position makes a difference. Linemen and tight ends receive the greatest amount of protection while skill players like quarterbacks, running backs and receivers actually had a slightly higher rate of injury while wearing the braces during games [Source: Albright, Najibi]. This tells us that the benefit of a brace for prevention is minimal. No other sports have shown any promise in the area of knee injury prevention with the use of knee braces.

ACL injuries usually occur as a result of twisting or forceful hyperextension of the knee with the foot planted. Because of the biomechanics of the knee and the fact that the brace is worn over immense layers of skin, fat and muscle, a brace cannot be effective in preventing ACL injuries. There is solid research indicating that training techniques can help reduce ACL injuries. The type of brace used for individuals with ACL injuries and after ACL reconstruction are those made of high-strength plastic or graphite, custom-made for the athlete. However, research has shown that using these types of braces, as well as the over-the-counter options, is not effective when used after surgery [Source: Birmingham]. The bottom line is that for most athletes and the physically active, knee braces will not help you prevent a knee injury.

Anterior knee pain, or pain around the kneecap, is one of the most common types of knee injuries. This pain is not due to a ligament injury and does not result in the loss of stability in the knee. However, the pain is generally related to how normally the kneecap (patella) works. Therefore, poor initial alignment or poor movement (tracking) can cause pain. For people experiencing this type of pain, knee braces with straps designed to guide the patella movement can be effective when combined with other therapy [Source: Lun]. It is the other factors addressed in therapy like leg flexibility, strength, motor control, footwear and activity alteration that will allow the knee to return to normal function. The knee brace can help reduce some of the painful symptoms while allowing for the therapy to be performed more effectively. The type of brace needed for this purpose can usually be ordered by a local physical therapist or orthopedic physician and costs anywhere from $50-$100.

Finally, an emerging use of knee braces is for the treatment of symptoms related to osteoarthritis of the knee. The theory is that the brace will pull on the bones above and below the knee to realign the leg. This realignment would then reduce the stress on areas of arthritis. Unfortunately, there has been no evidence that braces are effective in achieving realignment. There has been some mild improvement in pain. It is not known exactly why these people have decreased pain when using the brace, however, the effects do not appear to be permanent, nor do they slow the progression of arthritis [Source: Brouwer, Ramsey].

Overall, the use of knee braces for prevention of knee injuries, assisting in rehabilitation or prolonging function has not been shown to be effective. However, there are individuals experiencing anterior knee pain or osteoarthritis for whom using a brace works to decrease symptoms.  No matter what the cause or reason, we know that using knee braces is not the entire answer. Using a knee brace for symptom reduction is best combined with other treatments like therapy, exercise, dietary changes, body weight changes and activity alterations.

Back Braces

We are all probably aware of the near-epidemic level of lower back pain in our society. It affects nearly 70-80 percent of all Americans at some point in their lives. For some, turning to the use of a back brace or lumbar support is their treatment of choice. While this strategy could have some pain-relieving effects in the initial stages of injury recovery, as you will see, long-term use of a brace is rarely recommended. We will discuss the rationale for temporary use of a brace as well as the effects of long-term use.

As discussed in the general bracing article, back braces can be made of varying materials and varying levels of customization. The more customized braces tend to be used after back surgeries when widespread spinal stabilization is the primary goal. These braces are typically ordered by a surgeon or physical therapist and molded to a patient with heat-treated plastic. These are not the types of braces that you will find at your local pharmacy or sporting goods store.

The types of braces that most individuals with lower back pain are familiar with, are those made of neoprene and can include Velcro straps or buckles. These are the types that may be worn by employees who work in jobs that require frequent heavy lifting. The question to be considered is whether the braces actually help. It is also important to consider how long the brace might be useful and whether or not using one can prevent back pain.

As with the braces used immediately following surgery, lumbar support braces can be helpful after an initial lower back injury. The brace can be mildly effective for limiting movement at 1-2 segments of the spine in the lower back area. The limited movement can allow some injuries to heal without having excessive demand placed on the specific joints of that spinal area. However, consider that the demand removed from one area may just be transmitted to another area nearby.

While back braces can be effective for some people, the use of a brace for long-term or preventative use is not effective. The function of the spine is quite complicated. The series of muscles and ligaments that span the 33 levels of the spine work extremely well together. When adverse movements and loading cause an injury in one area, it will have an effect on many of the others. Likewise, the tissues of the spine need certain levels of loading and motion to maintain their normal function.

The phrase “use it or lose it” is quite appropriate when thinking about the spine. If a brace is used long-term, either after an injury or for preventative intensions, the spine will lose some of its normal function. Muscles and ligaments that do not have to work due to the support of the brace will weaken. This will demand more and more from the brace. At some point the brace cannot do that much work and an injury will result. Similarly, if the muscles and ligaments weaken with the use of a brace, then the spine is loaded at a time when a brace is not being worn. The spine will be at a higher risk of injury than it would have been had the brace not been used.

The use of a back brace can be helpful for some people for a short period of time. But using a brace or support for long-term or preventative reasons will only land you in a situation that you were trying to avoid. Consult your health care professional to see if this strategy could be of benefit to you. Remember that the use of the brace should be temporary. It will not fix a problem; it will just allow a specific part of the spine a little time to heal. Gaining or regaining normal function of that part of the spine should be your ultimate goal.

Lots More Information

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• Strain vs. Sprain
• Experimental Treatments for Back Pain
• What is a physical therapist?

Sources

• Verhagen, EA., Van Mechelen, W., De Vente, W. (2000). The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med, 10(4):291-6.
• Mickel, TJ., Bottoni, CR., Tsuji, G., Chang, K., Baum, L., Tokushige, KA. (2006). Prophylactic bracing versus taping for the prevention of ankle sprains in high school athletes: a prospective, randomized trial. J Foot Ankle Surg, 45(6):360-5.
• Olmsted, LC., Vela, LI., Denegar, CR., Hertel, J. (2004). Prophylactic Ankle Taping and Bracing: A Numbers-Needed-to-Treat and Cost-Benefit Analysis. J Athl Train, 39(1):95-100.
• Albright, JP., Powell, JW., Smith, W., Martindale, A., Crowley, E., Monroe, J., Miller, R., Connolly, J., Hill, BA., Miller, D., et al. (1994). Medial collateral ligament knee sprains in college football. Effectiveness of preventive braces. Amer. Journ. of Sports Med, 22(1):12-18.
• Najibi, S., Albright, JP. (2005). The use of knee braces, part 1: Prophylactic knee braces in contact sports. Amer. Journ. of Sports Med, 33(4):602-11.
• Birmingham, TB., Bryant, DM., Giffin, JR., Litchfield, RB., Kramer, JF., Donner, A., Fowler, PJ. (2008). A randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. Amer. Journ. of Sports Med, 36(4):648-55.
• Lun, VM., Wiley, JP., Meeuwisse, WH., Yanagawa, TL. (2006). Effectiveness of patellar bracing for treatment of patellofemoral pain syndrome. Clinic. Journ. of Sports Med, 16(6):530-1.
• Brouwer, RW., van Raaij, TM., Verhaar, JA., Coene, LN., Bierma-Zeinstra, SM. (2006). Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial. Osteoarthritis Cartilage, 14(8):777-83.
• Ramsey, DK., Briem, K., Axe, MJ., Snyder-Macker, L. (2007). A mechanical theory for the effectiveness of bracing for medial compartment osteoarthritis of the knee. Journ. of Bone & Joint Surgery, 89(11):2398-407.