How Do You Tell A Patient That Their Knee Brace Won't Work For Them?
Marc Darrow, M.D.,J.D.

There are many ways to treat a knee injury, surgery, rehabilitation, and less evasive techniques such as acupuncture, trigger point injections, prolotherapy, exercise and specialized training. These therapies and treatments are carried out by a wide range of medical professionals and while many rehabilitation specialists do not agree on which method is best, the one thing that most agree on is that the use of a knee brace to either prevent a knee injury or help support and provide comfort will not work for everyone.

One more thing that most clinicians agree on is that despite this, a great majority of patients want the braces regardless.

Making the Argument For and Against the Brace
It is difficult to convince a patient that a knee brace will not provide the comfort and support they anticipate in their situation when so many televised sporting events will show a superstar athlete with their knee wrapped in tape or ace bandage and in some instances wearing an obvious brace. However, it can be pointed out that if braces were very effective in prevention future injury, why wouldn’t every athlete wear them regardless of decreased mobility.

From every athlete to very few, why braces are no longer worn.

George Anderson is a legendary name among National Football League trainers. From 1960‑1994 he served as head and some times only trainer for the Oakland Raiders. During the 1970's the Raiders were a perennial football power and Anderson was responsible for keeping some of the game's best players on the field. This included the Raider's quarterback Ken Stabler, a numerous time all‑star, Super Bowl Winner and one of the game's top athletes.

When your star athlete suffers an injury, such as Stabler's medial collateral ligament injury, a team's medical staff will get somewhat creative to keep the player on the field. In this case, Anderson designed a special knee brace that would help prevent future injury to Stabler's MCL. Later this brace would be commercially marketed as the Anderson Knee Stabilizer.

When Anderson published his favorable review of his knee brace (1) football trainers in the high school, collegiate, and professional ranks hailed it not only as a means to get MCL (and ACL) injured players back on the field, but that it could also be used as a prophylactic knee brace. Soon, whoever could afford to outfit their team, or their best players or themselves with the brace did.

But just as quickly as the brace was embraced, research into knee bracing effectiveness for knee injuries began to appear which not only questioned whether knee bracing was effective but also suggested that they not only did not prevent injury, they may increase risk and reduce the athlete's motion and movement and hence performance. (2‑4)

Knee Braces in Brief
A great majority of medical studies on knee bracing has been done to affirm or question the use of Functional and Prophylactic knee braces in athletes because of the high visibility and money interests involved in sports. Further if the braces were so effective for athletes, one could imagine what type of knee injury support it would provide for the patient with a considerably lesser risk for future trauma and need for the maximum support it provided in contact sports.

Knee braces and their functions can be briefly described as the following:

Functional Braces
As mentioned above, functional braces are typically used by athletes who have suffered a significant knee injury and believe they will be benefited by them in controlling the rotation of the knee and stabilizing it. Medical literature questions the use of these braces in surgically repaired ACL and non‑surgically repaired ACL's. (5‑9)

Further, despite advances in technology patients have complained that the brace can slip out of place, cause discomfort and limit mobility. Additionally cost is a concern with custom made braces costing in the $1,000 range.

Some functional braces, such as the patellar supporting type are not as restrictive since their main purpose is to keep the patella from moving out of place.

Prophylactic Braces

Prophylactic braces are used to prevent injury to the knee. The most common form of this brace has a lateral post with two straps, one going around the tibia and one going around the femur.

It is these braces that present the greatest challenge to the practitioner. Many patients report that despite any evidence that the knee brace is helping their knee function or preventing an injury, the patient think it works. It is this thinking which has led some practitioners to allow their patients to leave them on. "As long as patients understand that a brace does not substitute for vigorous rehabilitation to improve strength, flexibility, and proprioception." (10)

A difficulty with this line of thinking is that the patient may injure themselves because they think that their knee is being protected. An athlete may play as if they had no injury, a patient may think they can quickly return to normal activities such as stair climbing or return to work sooner than they should following a surgery.(11)

Further, some studies suggest that the Prophylactic Braces may increase the incident of injury. Bracing the outside of the knee was thought to minimize tears of the MCL, but it has been suggested the braces increase stress load on the medial side of the knee and other points of the knee. (12,13)

Rehabilitative Braces
The use of rehabilitative braces are usually limited to the period immediately following an acute injury or surgery. These are large braces that usually extend from mid‑thigh to mid-calf with large hinges on either side of the knee and multiple straps to hold it in place. This brace is perhaps the most popular prescribed knee brace because they can offer many benefits that casting or splinting cannot including: adjustability for swelling and comfort and most importantly, to allow the knee a controlled range of motion. Increasing, rehabilitation specialists are being shown that moving an injured or surgical repaired knee as soon as possible greatly accelerates recovery time. (14)

However the American Academy of Orthopaedic Surgeons, in general, do not recommend these braces, citing that "the majority of scientific studies show no difference in final outcomes of anterior cruciate reconstructed knees, whether a brace is worn or not," "it does not appear that a brace is needed to support or protect a reconstruction in a well done surgical procedure" (15)

A Brace For The Arthritic Knee The Unloader/Osteoarthritis Brace
When the symptoms of osteoarthritis affect one compartment of the knee, either the medial compartment on the inner side of the knee or the lateral compartment on the outer side of the knee, but not both, the Unloader brace has been shown to decrease arthritis pain in selected studies by helping to shift the weight (or "unload" the weight) from the damaged area of the knee to the stronger, unaffected area of the knee. (16,17)

These knee braces are often prescribed to patients who can no longer tolerate or refuse anti‑inflammatory medications, and who the clinician feels will offer the greatest compliance as complaints about these braces from patients are that they are very expensive and often very bulky. Another problem is that these braces may cause bruising to the thighs and discomfort to the knee because they do not fit correctly-a well recognized problem with non-custom made braces. Typically a patient may decide on their own that this brace is too uncomfortable for them to wear.

Summary
In practice, the clinician and the patient should meet together to discuss all the pros and cons of the brace in their unique situation. In our practice we stress the following points on the patient when they request a prescription or recommendation for a brace understanding that we very rarely recommend the use of braces.

First, that the brace must never be thought of as a replacement for a medical treatment.

Second, that the patient must not be allowed to feel a sense of security that the brace will allow them, by itself, to return to a normal active life style.

Third, that perhaps with the exception of the Unloader/Osteoarthritis Brace, and only in certain situations, should a brace ever be used for any extended length of time.

Fourth, in our opinion, rehabilitation for medically treated knees must allow for increased movement and circulation to the knee, two important factors that maybe curtailed with improperly fitted or extended wear of a brace.

1. Anderson G, Zeman SC, Rosenfeld RT: The Anderson Knee Stabler. Physician Sportsmed 1979;7(6): 125‑127

2. Zemper ED. A two year prospective study of prophylactic knee braces in a national sample of college football players. Sports Training, Medicine and Rehabilitation, 1990; 1: 287  296.

3. Rovere GD, Haupt HA, Yates CS. Prophylactic knee bracing in college football. Am J Sports Med, 1987; 15(2): 111 116.

4. Hewson GF, Mendini RA, Wang JB. Prophylactic knee bracing in college football. Am J Sports Med, 1986; 14(4): 262 2666

5.Wilson LQ, Weltman JY, Martin DE, Weltman A . The effect of functional knee brace for ACL insufficiency during treadmill running. Medicine & Science in Sports & Exercise 1998; 30 5:655 664.

6. ACL insufficiency during treadmill running. Medicine & Science in Sports & Exercise 1998; 30 5:655 664.

7. Fujimoto E, Sumen Y, Ochi M, Ikuta Y: Spontaneous healing of acute anterior curciate ligament (ACL) injuries  conservative treatment using and extension block soft brace without anterior stabilization. Arch Orthop Trauma Surg 122: 212 216, 2002.

8. Birmingham TB, Kramer JF, Kirkley A, Inglis JT, Spaulding SJ, Vandervoort AA . Knee bracing after ACL reconstruction: effects on postural control and proprioception. Medicine & Science in Sports & Exercise 2001; 33 8:1253 1258.

9. Wojtys EM, Huston LJ: Custom fit vs. Off the shelf ACL functional braces. Amer J of Knee Surg 2001; 14(3): 157 162.

10. Does a knee brace decrease recurrent ACL injuries? Clinical Commentary: James L. Lord, M.D. The Journal of Family Practice October 2003

11. American Academy of Orthopaedic Surgeons. Position Statement on the use of knee braces. Document number 1124, October 1997. www.aaos.org/wordhtml/papers/position/1124.htm. Accessed: October 26, 2004

12. DeVita P, Torry M, Glover KL, Speroni DL. A functional knee brace alters joint torque and power patterns during walking and running. J Biomechanics 1996; 29 5:583 588

13. Jerosch J, Castro WHM, Hoffstetter I, Reer R . Secondary effects of knee braces on the intracompartmental pressure in the anterior tibial compartment. Acta Orthopaedica Belgica 1995; 61 1:37 42.

14. Nash CE. Mickan SM. Del Mar CB. Glasziou PP. Resting injured limbs delays recovery: A systematic review. The Journal of Family Practice September 2004:706 712.

15. American Academy of Orthopaedic Surgeons. Position Statement on the use of knee braces. Document number 1124, October 1997. www.aaos.org/wordhtml/papers/position/1124.htm. Accessed: October 26, 2004

16. Pollo FE, Otis JC, Backus SI, Warren RF, Wickiewicz TL: Reduction of Medical Compartment Loads with Valgus Bracing of the Osteoarthritic Knee. American Journal of Sports Medicine, 30 (3): 414 421, 2002.

17. Hewett TE, Noyes FR, Barber Westin SD, Heckmann TP. Decrease in knee joint pain and increase in function in patients with medial compartment arthrosis: a prospective analysis of valgus bracing. Orthopedics 1998; 21