What Can I Use Under a Leg Brace
Am Fam Physician. 2007 February i;75(three):342-348.
Commodity Sections
- Abstract
- Knee Braces
- Ankle Braces
- Wrist splints
- References
Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. At that place is good testify to back up the use of some braces and splints; others are used considering of subjective reports from patients, relatively low toll, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar caryatid for patellofemoral pain syndrome is neither recommended nor discouraged because good show for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the handling of acute talocrural joint sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of talocrural joint sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-upward later on bracing or splinting is essential to ensure proper fit and use. Am Fam Physician 2007;75:342–8. Copyright © 2007 American Academy of Family Physicians.)
Family unit physicians often must make decisions regarding the use of braces or splints in the management of musculoskeletal disorders. Bracing tin can be useful for astute injuries, and also for chronic conditions and in the prevention of injury. The purpose of braces and splints is to improve physical office, boring disease progression, and diminish pain. They can exist used to immobilize an unstable joint or fracture, to unload a portion of a articulation and meliorate pain and function, to eliminate range of motion in one direction, or to modify range of motion in one or more directions. They practice not supercede a good rehabilitative program, and the entire spectrum of treatment options should be explored and used as needed.
SORT: KEY RECOMMENDATIONS FOR Do
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Unloader (valgus) braces are recommended to reduce pain and improve function in patients with varus (medial compartment) osteoarthritis of the knee. | B | 6 |
| There is bereft evidence to support or discourage the utilize of patellar bracing for patellofemoral pain syndrome. | B | 7,8 |
| Functional handling of acute ankle sprains with semirigid or soft, lace-upwardly braces is recommended over immobilization. | A | 21 |
| A semirigid talocrural joint caryatid worn during functioning of high-adventure sports such as soccer or basketball is an option to reduce the gamble of future talocrural joint sprains for patients with a history of talocrural joint sprains. | A | 22 |
| A neutral wrist splint improves symptoms of and function with carpal tunnel syndrome when used for at least four weeks. | B | 25 |
| Wrist splints for carpal tunnel syndrome are well-nigh effective when they are worn total-fourth dimension. | B | 28 |
Accurate diagnosis of the injury is of import in determining whether a brace or splint is indicated. By and large, splints are for brusque-term use. Excessive, continuous use of a brace or splint can atomic number 82 to chronic pain and stiffness of a joint or to muscle weakness. Yet, long-term employ of some braces, such as a knee unloader brace, tin can help prevent progression of pain attributable to osteoarthritis of the human knee.
Given the limited bear witness on the use of braces and splints, it is especially important to apply a patient-centered approach, with consideration for individual patient's expectations and concerns and an understanding of the nature of their activity. For example, for loftier schoolhouse and collegiate athletes, there are specific rules on the types of protective equipment, splints, and braces that may be worn during competition.i Close follow-up later bracing or splinting is essential to ensure proper fit and use.
The nearly mutual types of braces and splints used in principal care and the quality of evidence to support current recommendations are discussed in the following. Braces and splints recommended for common musculoskeletal conditions are listed in Table i.
TABLE i
Braces and Splints Recommended for Musculoskeletal Conditions
| Musculoskeletal condition | Recommended brace or splint |
|---|---|
| Medial compartment osteoarthritis of the knee joint | Unloader (valgus) knee caryatid |
| Inductive knee joint hurting (patellofemoral pain syndrome) | Mixed results: consider no caryatid or knee sleeve with buttress |
| Acute knee joint injury (e.g., tendon or ligament rupture or fracture) | Knee immobilizer |
| Acute talocrural joint sprain | Semirigid stirrup brace (e.g., Aircast) or soft, lace-up brace |
| Prevention of recurrent ankle sprain | Semirigid stirrup brace (e.grand., Aircast) |
| Carpal tunnel syndrome | Neutral wrist splint |
Knee Braces
- Abstract
- Human knee Braces
- Ankle Braces
- Wrist splints
- References
Knee braces have been developed to unload the medial compartment for patients with varus osteoarthritis, to treat inductive articulatio genus hurting, and to immobilize the knee.
UNLOADER (VALGUS) Knee joint Brace
Unloader, or valgus, knee braces have been proposed as one treatment option for patients with medial compartment osteoarthritis of the knee. These braces are designed to apply an external valgus force, thereby reducing the load on the medial compartment and decreasing related hurting (Figure 1). Improved joint proprioception as well may play a role in reducing hurting.2,3 Indications for this blazon of brace include radiographic evidence of unicompartmental osteoarthritis (medial compartment) and varus malalignment.
Effigy 1.
Unloader (valgus) knee brace for medial compartment osteoarthritis.
Relatively few studies on bracing have been published, and most are not randomized controlled trials. A Cochrane systematic review4 identified merely one randomized controlled trial.ii In this study, 119 patients who had osteoarthritis associated with varus deformity of the knee were randomized to receive usual handling, unloader human knee brace, or neoprene sleeve to evaluate the effect of these therapies on functional condition and quality of life.two Although both the sleeve and the brace reduced pain and improved function, greater do good was found with the unloader caryatid. In a randomized crossover trial, 12 patients with varus osteoarthritis were given a unproblematic hinged brace or an unloader brace during ii six-month periods. Considering patients acted every bit their own controls, it was possible to place statistically and clinically significant benefits for the unloader caryatid that were greater than those of the hinged brace despite the small number of patients involved in the study.5 The American University of Orthopaedic Surgeons recommends unloader braces for the reduction of pain in patients with osteoarthritis of the knee.six This conservative pick is thought to extend the time before patients demand to undergo knee arthroplasty; information technology also can exist considered for those who are non candidates for surgery.
ANTERIOR KNEE Hurting BRACE
Anterior knee pain, also called patellofemoral pain syndrome (PFPS), is a common complaint amid young, agile patients. Its etiology is multifactorial and controversial, and the handling tin exist frustrating for the physician and the patient. Braces have been developed to address the nearly commonly accustomed etiology: malalignment of the patellofemoral joint. Typically, these braces are made of neoprene or a similar rubberband material, with boosted straps or a buttress for patellar support. The buttress tin be round, C-shaped, J-shaped, or H-shaped to help maintain tracking of the patella in the femoral groove. These braces are reasonably priced, and off-the-shelf models are acceptable (Effigy two).
Testify of the effectiveness of braces for treatment or prevention of PFPS is limited because of methodologic differences and shortcomings across studies. Two systematic reviews published in 2002 and 2003 concluded that, because of the low quality of bachelor studies, there is insufficient bear witness to support or to discourage the use of patellar bracing for PFPS.7,8 Also, an American University of Pediatricians technical report stated that there is no scientific prove to support the use of human knee sleeves.nine
Figure 2.
Patellar brace with lateral J-shaped pad for anterior knee pain (patellofemoral pain syndrome).
Two studies, published after the systematic reviews, produced contradictory results.10,11 In one small, anatomic study using magnetic resonance imaging, researchers examined patellar alignment, patellofemoral joint contact expanse, and pain response in patients with and those without bracing.ten They found significant changes in contact area and improvement in pain in the braced group simply piddling modify in patellar alignment. In a prospective randomized clinical trial published in 2005, researchers randomized 136 patients with inductive knee pain to treatment with home exercises, patellar bracing, exercises plus bracing, or exercises plus knee sleeve, and found no divergence in hurting ratings between the 4 groups afterwards 12 weeks.11 Small studies on military recruits accept reported a decrease in the incidence of anterior knee hurting with patellar bracing.12,13
Because of the express data and lack of clear recommendations and consensus on the effectiveness of patellar braces for the treatment or prevention of anterior knee pain, decisions regarding their utilize must be made on an private basis. Some patients may feel benefits; therefore, patients should be told that study results are inconclusive or mixed. A therapeutic trial of braces may be worthwhile because the braces are not expensive and no harmful effects accept been found. Nonetheless, a caryatid is no substitute for a expert rehabilitative program that includes strengthening, range-of-motion, and proprioceptive exercises.14–17
Knee IMMOBILIZER
Complete immobilization of the knee for an extended period is generally contraindicated because of the prolonged stiffness, musculus atrophy, and chronic hurting that event. Nonetheless, at that place are exceptions. Indications for the use of a human knee immobilizer (Effigy iii) include the acute (or presurgical) direction of quadriceps rupture, patellar tendon rupture, medial collateral ligament rupture, patellar fracture or dislocation, and a limited number of other astute traumatic knee injuries. The elapsing of immobilization and management of these conditions is variable and beyond the telescopic of this commodity.
Effigy iii.
Articulatio genus immobilizer for acute knee joint injuries.
OTHER KNEE BRACES
Other knee braces include prophylactic braces designed to prevent or limit the severity of knee injuries. These braces are used normally past football players to assist protect against medial collateral ligament injury. Functional knee braces are designed to provide stability to a ligament-deficient articulatio genus (e.g., in a patient with an anterior cruciate ligament tear before surgery) and also can be used for postsurgical repair. Rehabilitative knee braces are used postoperatively to allow protected range of motility.6 Recommendations for the proper selection and use of these braces are highly variable, complex, and often inconsistent; the pick seems to exist based on anecdotal experience and trial and error.
Ankle Braces
- Abstract
- Knee Braces
- Ankle Braces
- Wrist splints
- References
Talocrural joint sprains are 1 of the most common astute musculoskeletal injuries. The handling of lateral ankle sprains can be disruptive because of the many braces and splints that are bachelor for this injury. Ankle braces tin can exist divided into two categories: rigid and functional. Rigid braces substantially immobilize the entire ankle. Functional braces, which include semirigid (e.g., Aircast) and soft, lace-up braces, allow some plantar and dorsiflexion at the ankle while controlling for inversion and eversion. Semirigid braces are made of thermoplastic contoured lateral stirrups lined with air-filled foam pads for support of the medial and lateral malleoli. Supplemental air tin exist added to these air cells through an inlet port.18 Soft, lace-upwards braces are ordinarily made of canvas. Semirigid stirrup braces restrict ankle inversion and eversion more than than lace-upwards braces19 (Figures 4 and 5). External ankle support as well has been shown to improve proprioception, an of import component in the reduction of recurrent talocrural joint sprains.19
Figure iv.
Semirigid stirrup caryatid for ankle sprain.
Figure five.
Lace-up ankle brace for ankle sprain.
FUNCTIONAL Ankle BRACES
Complete immobilization of the ankle post-obit an acute talocrural joint sprain is no longer recommended. Early on mobilization using functional treatment is preferred.20 A Cochrane systematic review concluded that handling of astute talocrural joint sprains with functional braces leads to better outcomes (east.g., shorter time taken to render to piece of work or sport, less swelling and instability, greater overall satisfaction) compared with immobilization.21
A systematic review identified nine randomized trials that compared different functional treatment strategies (e.g., lace-up or semirigid brace, rubberband bandage) for astute lateral ankle ligament injuries.20 Because of the diversity of treatments and inconsistently reported follow-upwardly times, the most constructive functional treatment caryatid could non be identified. Still, lace-upwardly talocrural joint braces more effectively reduced short-term swelling than did semirigid talocrural joint braces. The near recent randomized controlled study, published in 2005, demonstrated comeback in ankle joint function after a moderate to astringent inversion injury using a semirigid (Aircast) brace.18 Thus, the evidence supports a functional treatment approach to inversion talocrural joint sprains with the utilise of a semirigid or soft, lace-upward caryatid.
PROPHYLACTIC ANKLE BRACES
Multiple studies have evaluated the effectiveness of ankle braces for the prevention of ankle sprains. In that location is adept evidence that semirigid braces help to foreclose ankle sprains during high-hazard sports such as soccer and basketball. Co-ordinate to a Cochrane systematic review, patients with a history of ankle sprain tin can be advised that wearing such a caryatid reduces their take a chance of future ankle sprains.22
Few studies recommend the duration for which talocrural joint braces should exist used. Nonetheless, one systematic review on the prevention of ankle sprains in sports recommends that patients who sustain moderate or astringent ankle sprains should wear an ankle caryatid during sports activity for at least six months following the injury.23
Wrist splints
- Abstract
- Knee Braces
- Ankle Braces
- Wrist splints
- References
Carpal tunnel syndrome is a common compression neuropathy, often treated initially with a splint to salve pressure on the median nerve. Few recent studies accept addressed the effectiveness of wrist splints in the handling of carpal tunnel syndrome, and no randomized controlled trials accept compared wrist splinting with no treatment. I systematic review concluded that there is limited evidence to support the use of splinting for upwardly to vi months,24 whereas a second review institute that a hand brace improved symptoms and function after four weeks.25
In that location are various options when prescribing a wrist splint, including neutral versus cock-up (extension) splints, nighttime versus total-time wear, duration of vesture, and custom versus prefabricated splints. One prospective report found that neutral splints relieved symptoms more than than cock-up splints (20 degrees of extension).26 The authors also institute that symptom relief was axiomatic in the first two weeks of wearing the splint; no boosted improvement was noted betwixt weeks 2 and 8 of wear.26 The first long-term prospective randomized written report to compare nighttime splint article of clothing with steroid injection found improvements in symptoms as well as motor and sensory nerve conduction velocities after 1 twelvemonth of wearing a splint at dark.27 Another randomized clinical trial, comparison symptoms and functional deficits in nighttime versus full-time splint wear, found the well-nigh meaning improvements at six-week follow-up in the group instructed to wear the splints full-time.28
Splints come with a dorsal or volar compartment in which metal or thermoplastic inserts can be placed. It is easier to mold a custom insert than it is to mold a prefabricated metal one29 (Figure 6). When fitting a prefabricated wrist splint, it is of import to detect the wrist position, because off-the-shelf wrist splints may have significant extension. Prefabricated splints, which tend to be more rigid and less comfortable than thermoplastic custom splints, typically are made to have 10 to 30 degrees of extension. Patients wearing prefabricated splints should render with the splint so that the angle can be adapted to the neutral position if necessary. Researchers suggest that prefabricated splints must exist adjusted to the neutral position in patients with carpal tunnel syndrome.28
Effigy 6.
(A) Neutral wrist splint for carpal tunnel syndrome. (B) Metal stay within the wrist splint in extension. (C) Metallic stay molded into the neutral position.
Thus, the evidence suggests that patients with carpal tunnel syndrome who choose to utilize a wrist splint should habiliment a neutral-position splint full-time for at least four weeks.
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REFERENCES
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ii. Kirkley A, Webster-Bogaert Southward, Litchfield R, Amendola A, MacDonald S, McCalden R, et al. The upshot of bracing on varus gonarthrosis. J Os Articulation Surg Am. 1999;81:539–48.
iii. Birmingham TB, Kramer JF, Kirkley A, Inglis JT, Spaulding SJ, Vandervoort AA. Knee bracing for medial compartment osteoarthritis: effects on proprioception and postural control. Rheumatology (Oxford). 2001;40:285–9.
4. Brouwer RW, Jakma TS, Verhagen AP, Verhaar JA, Bierma-Zeinstra SM. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. 2005;(one):CD004020.
v. Richards JD, Sanchez-Ballester J, Jones RK, Darke Northward, Livingstone BN. A comparison of knee braces during walking for the treatment of osteoarthritis of the medial compartment of the knee. J Bone Joint Surg Br. 2005;87:937–ix.
6. American Academy of Orthopaedic Surgeons. The use of genu braces. Accessed June 16, 2006, at: http://www.aaos.org/nigh/papers/position/1124.asp.
7. D'hondt NE, Struijs PA, Kerkhoffs GM, Verheul C, Lysens R, Aufdemkampe M, et al. Orthotic devices for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2002;(two):CD002267.
8. Bizzini Yard, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2003;33:4–20.
9. Martin TJ, for the Committee on Sports Medicine and Fitness. American University of Pediatrics: technical study: knee joint brace apply in the young athlete. Pediatrics. 2001;108:503–vii.
10. Powers CM, Ward SR, Chan LD, Chen YJ, Terk MR. The effect of bracing on patella alignment and patellofemoral articulation contact surface area. Med Sci Sports Exerc. 2004;36:1226–32.
11. Lun VM, Wiley JP, Meeuwisse WH, Yanagawa TL. Effectiveness of patellar bracing for handling of patellofemoral pain syndrome. Clin J Sport Med. 2005;fifteen:235–40.
12. BenGal S, Lowe J, Mann Thousand, Finsterbush A, Matan Y. The role of the knee brace in the prevention of anterior knee pain syndrome. Am J Sports Med. 1997;25:118–22.
13. Van Tiggelen D, Witvrouw E, Roget P, Cambier D, Danneels 50, Verdonk R. Result of bracing on the prevention of anterior knee pain—a prospective randomized study. Knee Surg Sports Traumatol Arthrosc. 2004;12:434–9.
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xv. Clark DI, Downing N, Mitchell J, Coulson 50, Syzpryt EP, Doherty M. Physiotherapy for inductive human knee pain: a randomised controlled trial. Ann Rheum Dis. 2000;59:700–four.
16. Crossley K, Bennell K, Light-green S, Cowan South, McConnell J. Physical therapy for patellofemoral hurting: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med. 2002;xxx:857–65.
17. Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med. 2002;thirty:447–56.
18. Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an rubberband back up bandage or an Aircast talocrural joint caryatid. Br J Sports Med. 2005;39:91–6.
xix. Cordova ML, Ingersoll CD, Palmieri RM. Efficacy of safe ankle support: an experimental perspective. J Athl Railroad train. 2002;37:446–57.
20. Kerkhoffs GM, Struijs PA, Marti RK, Assendelft WJ, Blankevoort L, van Dijk CN. Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;(3):CD002938.
21. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly K, Struijs PA, van Dijk CN. Immobilisation and functional treatment for astute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;(iii):CD003762.
22. Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing talocrural joint ligament injuries. Cochrane Database Syst Rev. 2001;(iii):CD000018.
23. Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med. 1999;27:753–60.
24. Goodyear-Smith F, Arroll B. What tin can family unit physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of nonsurgical management. Ann Fam Med. 2004;2:267–73.
25. O'Connor D, Marshall Southward, Massy-Westropp N. Not-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(one):CD003219.
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28. Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of nighttime-only versus full-time article of clothing instructions. Curvation Phys Med Rehabil. 2000;81:424–ix.
29. Sailer SM. The role of splinting and rehabilitation in the handling of carpal and cubital tunnel syndromes. Hand Clin. 1996;12:223–41.
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