Sports Braces

Posted on Jun 1, 2010 in Patient Care | 0 comments

Sorting the Data: Should You Be Recommending Ankle and Knee Braces to Prevent Sports Injuries?

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Let me start by saying it depends on whom you read and trust. And on what you want to believe.

The data is annoyingly conflicting and contradictory. This review has no pretentions that it represents an exhaustive or definite research of the literature, but rather it will serve as a review of some of the reviews and articles to help you best inform your sporting patients.

The high incidence of injuries to the lower extremity joints is well documented. Depending on the sport, the rate of knee injuries ranges between 13% and 71% of all sport injuries,[1-5] and half of these insults to the anterior cruciate.

In soccer as many as 1 in 5 injuries is to the ankle.[6] Acute ankle injuries account for between 10% and 30% of all sport injuries in young athletes,[7] and 40% of these may cause chronic problems.[8-9]

Anything we can do to protect our sports-loving patients could have an important impact.

Let’s start by looking at a 2005 article in the American Journal of Epidemiology.  It looked at discretionary use of protective gear in high school athletes and found that “Knee brace use and ankle brace use were associated with increased rates of knee injury (RR=1.61, 95% CI: 1.08, 2.41) and ankle injury (RR=1.74, 95% CI: 1.11, 2.72), respectively.” The authors suggest it is possibly “due to slippage of the brace during use, increased fatigue due to the energy cost of wearing a brace, or bias in the study.” This is conjecture only with no supporting data.

Knee pads on the other hand resulted in a reduced risk (RR) ratio of a whopping 0.44. Seems clear enough: put on the pads and skip the braces. Simple and cheap.

That is until you read in the Archives of Internal Medicine  that 18- to 21-year-old military cadets who wore knee braces reduced the risk of knee injuries by more than 50%.

That same review article reported on 4 different studies on ankle protection. All demonstrated reductions in injuries ranging from between an amazing 84% for a 6-month study of senior soccer players using ankle orthoses to a still impressive 40% drop that studied a similar group for one season using ankle stirrup orthoses.

“Interventions for Preventing Ankle Ligament Injuries” from the 2001 Cochrane Review concludes: “The main finding was a significant reduction in the number of ankle sprains in people allocated external ankle support (RR 0.53, 95% CI 0.40 to 0.69).” Most of the benefit proved to be in those with prior ankle injuries.

Another way to slice the Cochrane review data in the individual trials (not the pooled data) is to consider the Number Needed to Treat (NNT) to prevent a single injury. It ranged from 280 to 3000 athletes. (I guess that would be between 560 and 6000 ankles).

Sterret in The American Journal of Sports Medicine examined skiers with a history of anterior cruciate injuries. He found that “Nonbraced skiers were 2.74 times more likely to suffer subsequent injury than were braced skiers (odds ratio, 2.74 [CI, 1.2-4.9]).” Remember this was only studying patients with a documented history of ACL injury.

“The Potential Role of Prophylactic/Functional Knee Bracing in Preventing Knee Ligament Injury” by Neetu Rishiraj in Sports Medicine gives an honest answer in his review article. “In summary, the review of subjective and some objective publications suggests that a functional knee brace may offer stability to an ACL-deficient knee joint; however, research is limited on the use of a knee brace for prophylactic use in non-injured athletes. The limited research could be a result of fear of performance hindrance that has led to poor knee brace compliance.”

The American Association of Orthopaedics Surgeons in a position paper in 2004 stated, “At least one well-designed clinical trial has revealed a statistically significant reduction in medical collateral ligament injuries with the use of a prophylactic knee brace.”[10]

In summary, the data is strongest for those who have prior injuries to their ankles or knees. These patient would likely benefit from external bracing.

The data is not nearly as strong for those in whom we are trying to prevent the initial insult, although the majority of studies suggests that there may be a small benefit.

I know what I will be doing. I will be pushing harder for my patients with a history of trauma to the lower extremity to return to sports wearing a brace as protection. For the rest, I will share the data and let the athletes (and their parents) decide.

I am interested to hear from you and what you are doing? Please share.

Brian Koffman, MD
June 1, 2010

References

1. de Loës M, Dahlstedt LJ, Thomée R. A 7-year study on risk and costs of knee injuries in male and female youth participants in 12 sports. Scand J Med Sci Sports. 2000;10(2):90-97.
2. Oates KM, Van Eenenaam DP, Briggs K, et al. Comparative injury rates of uninjured, anterior cruciate ligament-deficient, and reconstructed knees in a skiing population. Am J Sports Med. 1999;27(5):606-610.
3. Delfico WE, Garrett WEJ. Mechanisms of injury of the anterior cruciate ligament in soccer players. Clin Sports Med. 1998;17:779-785.
4. Agel J, Dompier TP, Dick R, Marshall SW. Descriptive epidemiology of collegiate men’s ice hockey injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train. 2007;42:241-248.
5. Houck J. Muscle activation patterns of selected lower extremity muscles during stepping and cutting tasks. J Electromyogr Kinesiol. 2003;13:545-554.
6. Ekstrand J, Tropp H. The incidence of ankle sprains in soccer. Foot Ankle. 1990;11(1):41-44.
7. Perlman M, Leveille D, DeLeonibus J, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study. J Foot Surg. 1987;26(2):95-135.
8. Bennett WF. Lateral ankle sprains. Part II: acute and chronic treatment. Orthop Rev. 1994;23(6):504-510.
9. Safran MR, Benedetti RS, Bartolozzi AR III, Mandelbaum BR. Lateral ankle sprains: a comprehensive review Part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc. 1999;31(7):S429-S437.
10. American Association of Orthopaedics Surgeons. Position Paper: The Use of Knee Braces. Rosemont (IL): American Association of Orthopaedics Surgeons, 2004 Sep-Oct;15:419-429.