Knee Braces

CHAPTER 193 Knee Braces



Scott A. Paluska


The knee joint is the largest joint in the body, and traumatic, overuse, and degenerative knee injuries are common. Strength, flexibility, and technique modification have traditionally been essential components in the treatment of knee pain. Improved surgical techniques, arthroscopic advances, and smaller incisions have also enhanced therapy for knee disorders over the last few decades. More recently, knee braces have been used in an attempt to prevent or treat several knee conditions.


Knee braces typically fall into one of several broad categories:


• Prophylactic: Braces designed to reduce the occurrence or facilitate the recovery of injury to the knee’s medial collateral ligament (MCL) or lateral collateral ligament (LCL).

• Functional: Braces designed to restore normal knee kinematics, minimize tibial rotation, and reduce translation for anterior cruciate ligament (ACL)–deficient or ACL-reconstructed knees.

• Patellofemoral: Braces designed to keep the patella centered in the femoral trochlea and improve patellofemoral joint alignment.

• Postoperative: Braces designed to immobilize the knee or limit motion after surgery or an injury.

• Osteoarthritics: Braces designed to diminish painful forces exerted on an affected knee’s tibial-femoral compartment (medial or lateral) for unicompartmental knee osteoarthritis.

Despite their popularity, the appropriate indications and true benefits of many knee braces have not been clearly defined or validated by rigorous research. In addition, brace manufacturers market several different knee braces to address conditions that may be nonspecific and diverse. As a result, confusion often exists regarding when and if knee braces should be used for the prevention or treatment of various knee abnormalities. At this point, it can be said that some knee braces may minimize knee injuries, but the efficacy of most braces has not been confirmed by well-controlled studies. In general, most individuals using knee braces express subjective symptomatic improvements that exceed objective findings. Clinicians must assess the costs and potential risks of knee braces when deciding to use them for individuals. Although knee braces appear relatively safe when used appropriately, they should be used only in conjunction with appropriate education, muscular rehabilitation, technique enhancement, and activity modification.



Indications



Prophylactic Knee Braces



• MCL or LCL injury protection during significant valgus or varus knee forces

• MCL or LCL stabilization during recovery following an MCL or LCL sprain

• Athletes or individuals at high risk for MCL or LCL injuries


Functional Knee Braces



• Mild-to-moderate ACL instability

• ACL-deficient knees treated nonsurgically

• Postoperative support following ACL reconstruction

• Support for mild-to-moderate posterior cruciate ligament (PCL) or MCL instability


Patellofemoral Knee Braces



• Patellar subluxation or dislocation

• Anterior knee pain syndromes

• Patellar tendonitis

• Osgood-Schlatter disease

• Compression of a knee effusion


Postoperative Knee Braces



• Stabilization following an acute knee injury or ligament sprain

• Postoperative immobilization

• Customized range-of-motion limitations for various knee conditions

• Stabilization following a femoral or tibial fracture

• Graft protection following knee ligament reconstruction


Osteoarthritis Knee Braces



• Unicompartmental, symptomatic tibial-femoral knee osteoarthritis

• Neutral or varus knee alignment (for a valgus-force brace)

• Neutral or valgus alignment (for a varus-force brace)


Contraindications



In General



• Unstable knees requiring prompt surgical management

• Body contours that preclude effective brace positioning

• Regional compartment syndrome that may be exacerbated by brace tension

• Open wounds, cellulitis, or lacerations that will be occluded by the brace


Prophylactic Knee Braces


Prophylactic knee braces should not be used for control of tibial translation or rotation in ACL-deficient knees.



Functional Knee Braces


Functional knee braces should not be used for complex knee injuries, such as posterolateral corner injuries.



Patellofemoral Knee Braces



• Knee disorders unrelated to the patellofemoral joint

• Moderate-to-severe patellofemoral osteoarthritis


Osteoarthritis Knee Braces



• Multicompartmental knee osteoarthritis

• Moderate-to-severe patellofemoral osteoarthritis

• Knee arthritis related to other conditions such as inflammatory, infectious, or autoimmune


Equipment and Supplies



In General



• Tape measure

• Athletic tape (optional)

• Skin razor (optional)

• Prewrap on skin under brace to limit brace migration (optional, not beneficial for patellofemoral braces)

• Elastic wrap or brace cover (optional)


Prophylactic Knee Braces



• Custom or off-the-shelf (prefabricated) brace with unilateral or bilateral bars

• In addition to athletic tape, there may be manufacturer-supplied hook-and-pile fasteners


Functional Knee Braces



• Custom or off-the-shelf (prefabricated) brace

• In place of tape measure, there may be specific measuring device supplied by the brace manufacturer


Patellofemoral Knee Braces



• Custom or off-the-shelf (prefabricated) brace

• Counterbalancing straps (optional)

• Patellar buttresses (optional)

• Inflation device for inflatable air pocket (optional)


Postoperative Knee Braces


An off-the-shelf (prefabricated) universal-sized brace is used postoperatively.



Osteoarthritis Knee Braces


A custom or off-the-shelf (prefabricated) brace is used in cases of osteoarthritis.



Preprocedure Patient Education


The clinician should identify the appropriate indication for using a knee brace and explain that the brace may or may not be helpful for a given individual. An appropriately sized prefabricated brace is generally sufficient for most individuals. Although custom braces may distribute weight and fit better and be made of materials more worthwhile for high-level athletes or individuals with abnormal limb contours, they are more expensive. If the individual is a minor, consent should be obtained from the parent or guardian. (See the sample patient consent form online at www.expertconsult.com.) The initial fitting and brace application should be scheduled with adequate time allowed for correct sizing and an explanation of recommended brace care and usage. (See the sample patient education form online at www.expertconsult.com.)



Procedure



Prophylactic Knee Braces


Prophylactic knee braces are used to prevent injury to the MCL or LCL during contact sports or to provide stability during recovery after an MCL or LCL sprain (Fig. 193-1). Although the routine use prophylactic knee braces for collateral ligament injury prevention may be controversial, they do have a more well-defined role during MCL or LCL rehabilitation. Prophylactic knee braces are available as custom or off-the-shelf (prefabricated) models (Figs. 193-2 and 193-3). They have either a single lateral hinged support or bilateral supports with polycentric hinges that are connected by fabric and closures. Cost is greater for custom models, which appear to have greater efficacy during both knee flexion and extension. Although high-level athletes may profit from the weight distribution and fit characteristics of a custom brace, a prefabricated brace is sufficient for most individuals. At-risk athletes, such as football linemen, may particularly benefit from wearing well-fitting prophylactic knee braces on both knees during practices and games. However, it should be noted that prophylactic knee brace use may have a negative impact on an athlete’s speed, agility, fatigability, and endurance.


1 Obtain the longest brace that the individual can wear comfortably (≥50 cm).

2 Select a brace with either unilateral or bilateral bars based on personal preference and cost. Bilateral bars may improve the brace’s ability to transfer loads placed on the knee joint during impact.

3 Shave the skin under the brace, if desired, to maximize brace-to-skin contact.

4 Secure and adjust the athletic tape or brace enclosures to minimize brace movement.

5 Align the hinge(s) with the femoral condyles to minimize knee range-of-motion attenuation. Correct hinge placement relative to the knee joint is critical for optimal brace efficacy. The side bars may be bent if needed to accommodate the limb contours.

6 Cover the brace with the elastic wrap or brace cover, if desired, to minimize brace deterioration or injury to others during activities.

7 Tighten and adjust the brace regularly during prolonged athletic activities. It is common for the brace to migrate distally.

8 Hand wash and thoroughly dry the brace occasionally to prolong its life and reduce skin irritation.

9 Inspect the brace regularly for signs of deterioration or excessive wear.

10 Periodically apply a dry lubricant, such as Teflon spray, to the hinges.

11 Replace a broken or damaged brace.

image

Figure 193-1 Representative prophylactic knee brace. A, Unilateral hinged bar prophylactic knee brace in a neutral position. B, Valgus-applied force causing increased medial collateral ligament (MCL) tension and potential ligament rupture. Use of the brace would hopefully prevent the MCL tear seen here.


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Figure 193-2 Representative prophylactic knee brace with bilateral hinged bars seen from the front.


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Figure 193-3 Representative prophylactic knee brace with bilateral hinged bars seen from the side.

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  4. Compartment Syndrome Evaluation

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Knee Braces

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