The Role of Orthoses in the Care of Knee Ligament Injuries
Kenneth E. DeHaven, M.D. *
The role of braces in the management of knee ligament injuries, particularly in high risk athletics, continues to receive a great deal of attention. There are a multitude of braces currently being manufactured and marketed with various claims relating to the effectiveness, comfort, durability, and cost.
Two key questions remain for most clinicians: (1) Should knee braces be used at all?, and (2) If so, what type of brace should be used and under what circumstances? At present there is a paucity of scientific data available to answer either of these questions with certainty, but there are encouraging signs that this essential information will be forthcoming from current and future research. Until an adequate scientific basis has been established it is necessary to develop a philosophy about bracing in athletics that is consistent with the data that is available and our clinical observations.
Should braces be used at all?
There is frequently an ego problem for both the athlete (who views a brace as a sign of weakness) and the physician (concern that a brace reflects less than optimal results) who delight in the statement "Doc, I don't need that brace—I can run and cut without it." Definitive treatment, whether rehabilitation or surgery followed by rehabilitation, must provide the functional stability, and it is rare in my experience that an unstable knee is made stable simply by applying a brace. However, no matter how good it might feel to the athlete, a knee that has previously sustained major ligament injury is not normal, and in fact has suffered ligament disruption at a time when it was normal. The role of bracing, therefore, is not to provide stability but to help prevent reinjury by keeping the knee from going into extreme positions when subjected to sudden stress. When presented in this light, the concept of protective bracing after major ligament injury to the knee is more reasonable and more acceptable to both the athlete and the physician.
What type of brace should be used and under what circumstances?
While not definitively established, it appears that the beneficial effects of knee orthoses are related not only to their mechanical strength but also to providing increased proprioceptive input from the knee area (which can explain how some patients feel more stable in braces that provide little or no mechanical support). Optimal support is provided by braces that protect against varus/valgus and hyperextension stresses and are utilized routinely in our Center following ligament repair or reconstruction of collateral and/or cruciate ligaments. The brace is initially worn for ambulation in the early postoperative period (two or four months) and later for agility, contact, or other types of "high risk" sports. Less sophisticated braces that provide just varus/valgus support usually are sufficient for athletes returning to similar sports in the same season following Grade II collateral ligament sprains. The practicality, efficacy, and cost effectiveness of prophylactic bracing to prevent injury in contact sports such as football is also a topic of great interest but remains unresolved at present.
It is important to emphasize that this represents personal philosophy and recommendations based upon the information available at this time. It is recognized that while these concepts appear to be reasonable they are largely unproven, and there continues to be great need for more biomechanical and clinical research to firmly establish a scientific basis for knee bracing in athletics.
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