10 luke best brace - ucsf cme

12/10/2016

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What’s the Best Brace for this Patient? Cases from Sports Clinic

Tim Baldwin, MA, ATC, CFo

Michael Mayes, MS, ATC, CFo

Dr. Anthony Luke, MD

Plan• Brief overview of the fitting process

• Case-based discussion of orthotic devices

– Knee OA, Patella Instability, ACL (acute + reconstr uction), GH Instability, and Ankle Sprain

– Cases to consider

• Try things on!

Fitting Process

• Inspect Orthosis

• Explain purpose and objective of orthosis

– Advantages and Disadvantages

– Determine expectations

• Explain the patient’s roles and responsibilities/ex pectations

• Don’t promise cures

Fitting Process Continued

• Instruct in don and doff

– Make patient don without your assistance

– Make patient take a picture of the instructions

• Explain adjustments, potential problems, and care o f orthosis

• Explain skin care

– Environmental concerns

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Case #1 Medial Meniscus Tear/Medial OA

• 64 y.o. female who slipped on the pavement and felt a “pop” in her right knee, now has medial knee pain and mild swelling.

• Suspicion of medial meniscus tear in setting of medial compartment OA

• Treat with conservative management initially

– PT, Cortisone injection, activity modification, weight loss (as appropriate) consider orthotics, or bracing


• What type of brace might be helpful for this patient?

• Unloader brace!– Unloader braces may also be used for younger

patients or athletes with meniscus deficiency, chondral injuries or collateral ligament injuries.

• Prescription for valgus unloader brace to unload medial compartment


• Evidence supporting use of unloader brace rather than neoprene sleeve?

• Unloader braces have been shown to be more effective than neoprene sleeves for reducing pain and improving disease-specific quality of life (Kirkley et al.)


• Unloader brace may also be used for chondral injuri es, meniscus deficiency or MCL injuries.

• Considerations regarding unloader braces:

– Unicompartmental arthritis

– Lower extremity alignment

– Patient’s body habitus

– Activity goals

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Three Point Pressure System

• Creates valgus force to unload medial compartment

Unloader Brace Examples

Ossur Unloader OneTownsend Rebel Reliever

BregFreestyle

Breg Fusion OA Plus

Brace Pros Cons

• Minimalist design• Single upright(single joint)• Easy to use

• Straps cross at fibular head

• Single upright can be difficult if billing

• Fits well on patients with genu valgum/varum

• Difficult to adjust• Not much padding on

pressure points

• Single upright design• Very easy to don and doff• Easily adjusted

• Can be hot due to little ventilation

• May stretch over time

• Double upright• Easiest to use• Cheaper

• Can be uncomfortable on patients with prominent tibial tuberosity

OssurUnloader One

Townsend Rebel Reliever

BregFreestyle

Breg Fusion OA Plus

Unloader Brace Measuring & Fitting

• Most require measurement of knee circumference 6” ab ove and below patella

– When in doubt, size up

• Ensure full contact on condyles

• Easiest to fit when patient is seated with slight b end in knee

• Have patient stand and walk with no unloading

• Set correction then have patient walk again

• General rule of thumb: only increase correction by .5-1 on the dial

– Only increase correction every few days

– Gradually increase time of use

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Three Outcomes To Watch For…

• Correction feels great

– Don’t change the dial

• Patient feels mild decrease of pain medially– Increase correction by .5 and see if symptoms change for 2-3 days

– Continue process of “fine tuning”

• Discomfort/pain on lateral knee– Could be pressure on lateral condyle or lateral meniscus

– Decrease dial by .5-1 and monitor symptoms

Case #2 Patella Maltracking/Instability

• 16 year old female soccer player with history of lateral patella subluxation 1 year ago

– Managed non-operatively with PT

• Athlete is concerned with aesthetics and a brace being “too bulky” for return to soccer


• Patella bracing has been shown to…

– Reduce pain

– Decrease lateral patellar displacement(Powers et al., Becher et al. Khadavi et al.)

• Patella bracing has not been shown to prevent dislo cations.

• Goal of patella bracing or taping is to control exc essive patella motion.

Patella Tracking Brace Measuring and Fitting

• Most braces will require measurements 6” above and b elow patella

– Some need knee width at joint line

• Ensure full contact on lateral edge of patella

• Easiest to fit with patient seated and knee fully e xtended

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Patellar Tracking Brace Examples

DonJoy Reaction Web

Breg PTO Soft Knee Brace

Breg FreeRunner Knee Brace

DonJoy Hinged Lateral J

DonJoy Tru-Pull Lite

Brace Pros Cons

Breg PTO • Can be most helpful in chronic subluxations or acute settings

• Can adjust medial pull

• Bulky• Little medial-Lateral

support of knee

DonJoy Lateral J • Provides pressure on patella tendon to relieve anterior knee pain

• Cannot adjust medial pull• Full skin coverage

Breg FreeRunner • Medial pull increases with knee flexion

• Less bulky• Ideal for distance running

• Little medial-lateralsupport of knee

Don Joy TruPull Lite • Tacky surface of lateral buttress

• Less bulky

• Little medial-lateral support of knee

• Full skin coverage• Stretches out


• For this case we decided to fit for the DonJoy React ion Web

– Less bulky option

– Has been shown to decrease anterior knee pain

– We have seen good results with our patients

DonJoy Reaction Web Brace

• PROS – Gives an extension assist

during rehab

– Allows skin to breathe

– Contours to knee

– Good for athletes worried about aesthetics

– Allows an option for those less extreme instability cases

– Can bill as a hinged knee brace

• CONS – Velcro wears down quickly

– Less rigid support

– Lacking Medial-Lateral Support

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Case #3 ACL Tear Acute

•Patient was skiing and ski got caught, boot didn’t release, felt a pop and was able to slowly ski down the hill

•Had swelling the next day

•Went to ED and placed in knee immobilizer and crutches

–Seeing you for initial evaluation

Case #3 ACL Tear Acute

• Rule out Fracture• Knee Immobilizer for short

term

Case #3 ACL Tear Acute T-scope Example

• One size fits nobody

• Extend distal end to prevent sliding

• Must pull tight

• Control ROM, can lock 90-0 degrees

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Case #3 ACL Reconstruction

• 22 year-old athlete presents 9 months after ACL reconstruction.

• Athlete has completed a full rehab course and wants to return to playing soccer on club team

• What goes into decision making for choosing a funct ional brace for the athlete?

– Variability in surgeon bracing practices

– Goal is to protect ACL graft from excessive strain and elongation, although no evidence of significant benefit

– Subjective higher confidence in the knee at 6 and 12 months post-operatively compared with no brace.

(Birmingham TB et al)

Case #3 ACL Reconstruction

• We have many options…

– Breg

– DonJoy

– Townsend

– Ossur

Brace Pros Cons

• Cheaper option than most• Easy to bill out for Medi-Cal

and still get reimbursed

• Tibial portion can dig into prominent tibial tuberosity

• Can be difficult fitting on with shin guards

• Popular among extreme sport athletes

• Includes tibial extension which can help with protection during falls

• Has an option to attach to ski boot

• Also makes brace for surfing (Cti with AMS system)



Breg

Ossur

Brace Pros Cons

• Ideal for soccer player because of no tibial bar

• Allows room for shin guards and ski boots (short tibial cuff option)

• Least cumbersome • Force Point option dampens

tendency toward hyperextension in hypermobile athletes

• Donjoy a22 Lightweight but strong for Fast athletes

• Can be slightly more expensive

• Has option for semi-customized brace

• Ideal for athletes with large thighs and smaller calves



DonJoy

Townsend

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Case # 4 Glenohumeral Instability

• 17 year old football player with history of first time anterior shoulder dislocation 2 months ago

• Dislocation occurred in preseason game while arm tackling

• Shoulder was reduced in the ED

Case # 4 Glenohumeral Instability

• Patient underwent short period of immobilization, fu ll Physical Therapy protocol, non operative treatment

• Recently cleared for full participation

• Risk of recurrent instability?

Case # 4 Glenohumeral instability

• Counsel your patients (and parents) regarding risk of recurrence. Bracing is not always successful.

Recurrence Related to AgeAge Recurrence~20 years 94%21-30 years 79%31-40 years 50%> 40 years 14%

(Rowe et al.)

Case # 4 Glenohumeral instability

• Considerations regarding bracing

– Sport and position specific risks?

– Timing for return to play

– Duration of treatment

• Bracing provides subjective improved stability, alt hough no evidence of decreased rate of dislocation. (Owens et al.)

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Shoulder Bracing Examples

Sully Shoulder StabilizerRehband Acro Comfort Shoulder Brace Support

Breg Shoulder Stabilizer

Brace Pros Cons (Never covered by Insurance)

• Minimalist design allowsfor more overhead reach if desired

• Used by a lot in throwing athletes

• Fabric stretches• May not prevent shoulder

abd. and ER as well as other features braces

• Less restriction of horizontal abd.

• Minimalist design• Stronger fabric to resist

stretching• Fits left or right shoulder

• May not resist ER• May shift with athletic

activity

• Will restrict shoulder abd. and horizontal abd.

• Can be of benefit in tackling sports

• May not resist ER

Sully Shoulder Stabilizer

Rehband AcroComfort Shoulder Brace Support

Breg Shoulder Stabilizer

Sawa Shoulder Stabilizer

• Measurement of chest circumference across nipple line

• Designed to limit abduction and external rotation

• Set Abduction and ER straps at 45 degrees to keep GH head most protected

• Brace will allow for ROM pastpreset 45 degrees (Weise et al.)

• Keep in mind that the brace may loosen during activity and may need to be adjusted

Sawa Shoulder Stabilizer Continued• Main goal = restrict shoulder abduction to < 90 deg rees

External Rotation

Abduction

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Case #5 Grade 3 Ankle Sprain/Avulsion

• 16 y/o male soccer player got ankle caught in turf and inverted.

• Unable to FWB on ankle after injury

• Presents with noticeable limp, and inflammation

• Avulsion fracture of ATFL

Case #5 Grade 3 Ankle Sprain/Avulsion cont.

• Athlete reports Hx of recurrent lateral ankle sprains

• Significant inflammatory response

• Significant decrease in AROM / PROM

• R/O high ankle sprain/syndesmosis injury

• XR reveals avulsion fx of ATFL

Case #5 Grade 3 Ankle Sprain/Avulsion cont.Device Pros Cons

CAM BootAnkle immobilization,can WB in, tall and short versions, compression

Can be heavy, LLD due to height, don/doff issues

Stirr-UpM/L support, compression,some can freeze for cryo

No dorsi/plantarflexion control, bulky

ASOInversion/eversion, limit dorsi/plantarflexion,compression

Bulky, difficult to don/doff

A60Slim design, easy don/doff, good for every day use

Prevent inversion only, not as much control

Case #5 Grade 3 Ankle Sprain/Avulsion cont.

• 4-6 Weeks– Conservative tx w/ CAM

Boot

– Sized by pt's shoe size

– Instruct to walk as normal as possible with boot

• No limping

– May use crutches for NWB until pain decreases

• 6 weeks and beyond– Transition to ASO

• Size to shoe size

• Avoid pressure around styloid process

– This is not a permanent treatment

• Pt must cont. with rehabilitative exercises with ATC or PT

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CAM Boot Vs. Stirr-Up

• Syndesmotic Sprain– Conservative tx w/ CAM

Boot• 4-6 weeks

– Physical Therapy

• Ankle Sprain (I-III)– Stirr-Up*

• Until ready to RTP

– ASO• When RTP

• Not a long term solution

• Cont. therapeutic exercises

Other Cases to Consider

• Carpal tunnel syndrome

– Cock-up wrist splint at night

• Mallet finger

– Stack splint

• PCL injury

– Add posterior bump to t-scope

• Rotator cuff injury

– Abduction sling

“ Come with me and you’ll see a world of pure imagination" – Willy Wonka

Thank you

12/10/2016

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References• Amis AA, Senavongse W, Bull AM. Patellofemoral kinem atics during knee flexion-extension: an

in vitro study. J Orthop Res. 2006;24(12):2201-11.

• Becher C, Schumacher T, Fleischer B, Ettinger M, Smi th T, Ostermeier S. The effects of a dynamic patellar realignment brace on disease deter minants for patellofemoral instability in the upright weight-bearing condition. J Orthop Surg Res. 2015;10:126.

• Birmingham TB, Bryand DM, Giffin JR, Litchfield RB, K ramer JF, Donner A, Fowler PJ. A randomized controlled trial comparing the effective ness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstr uction. Am J Sports Med. 2008 Apr;36(4):648-55.

• Hart HF, Collins NJ, Ackland DC, Cowan SM, Hunt MA, Crossley KM. Immediate Effects of a Brace on Gait Biomechanics for Predominant Lateral Knee Osteoarthritis and Valgus Malalignment After Anterior Cruciate Ligament Recon struction. Am J Sports Med. 2016;44(4):865-73.

• J. Khadavi, M. , Chen, Y. and Fredericson, M. (2015 ) A Novel Knee Orthosis in the Treatment of Patellofemoral Pain Syndrome. Open Journal of Thera py and Rehabilitation, 3, 56-61. doi: 10.4236/ojtr.2015.32008.

• Kirkley A, Webster-Bogaert S, Litchfield R, Amendola A , MacDonald S, McCalden R, Fowler P. The effect of bracing on varus gonasrthrosis. J Bone Joint Surg Am. 1999 Apr; 81(4):539-48.

References

• ing Active and Passive Shoulder Range of Motion in Collegiate Football Players. J AthlTrain. 2004;39(2):151-155.

• Owens, BD, Dickens JF, Kilcoyne KG, Rue JP. Manageme nt of mid-season traumatic anterior shoulder instability in athletes. J Am Aca d Orthop Surg. 2012;Aug;20(8):518-26.

• Papasoulis E, Drosos GI, Ververidis AN, Verettas DA. Fu nctional bracing of humeral shaft fractures. A review of clinical studies. Injury. 20 10;41(7):e21-27.

• Powers CM, Ward SR, Chan LD, Chen YJ, Terk MR. The e ffect of bracing on patella alignment and patellofemoral joint contact area. Med Sci Sports Exerc. 2004;36(7):1226-32.

• Rowe CR, . Acute and recurrent anterior dislocation s of the shoulder. Ortho Clin North Am 1980;11:253-70.

• Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82(4):478-86.

• Weise K, Sitler MR, Tierney R, Swanik KA. Effectivene ss of Glenohumeral-Joint Stability Braces in Limit

10 luke best brace - ucsf cme

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