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Bob's ACL WWWBoard
Re: Best knee brace for protection in football -- Custom-made is always best....
Posted By: Michael Frind
Date: Sunday, 24 February 2008, at 12:39 p.m.
In Response To: best knee brace for protection during football (redpony)
Dear Red,
You noted that your son "injured his left knee in 8th and 9th grade and both resolved themselves". Not knowing the exact nature of the injuries (including the forcing the knee was subjected to), it might be appropriate to consider the left knee as harbouring some lingering injury history. If the knee ever manifested itself as unstable (even if it just gave way during the injury events themselves), then some latent ligamentous damage should be expected. With this in mind, it is important that your son maintain strong leg muscles (which he probably already has, given that he is 6'3" and 270 lbs). And, the wearing of functional bracing, even if just in the prophylactic context (i.e. to prevent injury), would be very wise indeed.
I would be intrigued to hear more about the injuries to your son's left knee in 8th and 9th grade. How was it forced (e.g. twisting, forced from the side, violently hyperextended, etc.)? In which activity did the incident occur? Did the knee ever give way? Did it ever feel unstable for any length of time? Were any noises heard from the knee? Did the knee ever swell up or lock? Did your son ever complain about it? Was the knee examined by a knee-experienced orthopedist at the time of each injury event? What diagnostic avenues (e.g. manual-manipulation testing, MRI scanning) were pursued? What diagnoses were conferred? These details might make a very strong argument for prescription of custom-made bracing, at least for the left knee.
Knee injuries are serious business. Much of this has to do with biomechanics: the knee is the human body's most-vulnerable-to-severe-injury joint. This is due to the enormously long lever arms of the leg bones (tibia and femur, each of which is over twice as long as a car-tire wrench), the very high dynamic loadings (these are much greater than the simple static weight of the person; to get an idea of dynamic loadings, observe what a bathroom scale reads when your son jumps on it with full force), and the near-complete absence of native bony stability (so, the knee depends very heavily on its four main ligaments for stability). Although strong leg muscles are important in preventing many types of knee injuries, during situations of unexpected forcing, the muscles might not be activated in time, and so the knee ligaments would be on their own. Here we see another reason why functional bracing is so valuable.
As someone whose bilateral partial cruciate-ligament tearing has left me dependent upon functional bracing for most of my activities (in my case, the partial tearing is minor enough that I have never had any knee instability), I have spent a lot of time researching the various offerings from various manufacturers. I have also written a lot on functional knee bracing in my previous postings, which can be found by searching this forum (and also in the Interim Archive). I will cover the essentials here.
You indicated that the OS wants your son to wear functional bracing during football (American football, as distinct from soccer in Europe). This is very prudent, because functional braces provide excellent protection against sideways forcing and injurious hyperextension. Both of these types of injury scenario are extremely common in collision-type sports such as football. Nothing is more heartbreaking than seeing an unbraced knee injured via sideways forcing or injurious hyperextension in football.
However, it is important to keep in mind that planting-and-twisting injuries are something which a brace cannot protect very well against. This is an inescapable consequence of the soft tissues that surround the leg bones (to illustrate this, grab your leg and twist). It is absolutely essential that your son bear this in mind when playing football. To avoid twisting-type knee injuries, it is helpful to practice pivoting on the front portion of the foot (instead of planting the entire shoe sole and quickly changing direction). Different types of shoes (i.e. different cleat patterns) and various playing surfaces (e.g. natural turf versus various artificial surfaces) will also affect pivoting characteristics. However, a knee-friendly pivoting technique will be helpful in any case.
Also, it is important to remember that functional bracing, whether off-the-shelf or custom-made (but especially if custom-made) is very different from low-end protective devices sold as "prophylactic braces". When reading reports or studies (including those in this forum's Knee Library), it is important to keep this in mind. Again, it is also important to remember why braces are not very helpful against plant-and-twist injuries. Anyone who claims that "braces don't work" is forgetting the twisting problem and is ignoring that braces protect beautifully against sideways forcing and injurious hyperextension.
You mentioned that your OS wants your son to get the CTi-OTS, i.e. an off-the-shelf brace from Ossur. Because this is the only brace make you mentioned, I will focus my discussion primarily on the Ossur products, but I will touch on the products of some other widely known firms too.
The CTi-OTS will provide good protection against injurious hyperextension, but its flexible cuffs will not provide the best possible protection against sideways forcing. (The CTi-OTS is basically the same as a former product known as the Edge.) This is one reason I recommend choosing the CTi-Custom (formerly known as the CTi2), which has rigid side arms (and for extra protection, rigid medial arms can be ordered as well, although the standard lateral rigid arms are adequate).
Of all the braces available, the CTi-Custom would be my first choice. This is the only carbon-fibre-composite brace that has a foam core (for maximum strength at minimum weight) but that also has a full tibial shell. This enables it to grasp the tibial crest (shinbone, which you can easily palpate at the front of the lower leg), thus ensuring that the brace locates itself on the leg consistently. And, the tibial crest is the only bony landmark that is suitable for brace anchorage, so it makes sense for a brace's lower shell to incorporate a furrow that interfaces with it. Grasping the tibial crest as snugly as possible also enables the brace to help protect against twisting (although this is not enough to ensure protection against twisting-type injuries, as I warned about earlier).
The CTi-Custom will be somewhat more expensive than an off-the-shelf brace, but sometimes it can be had for hundreds of dollars less than the typical $1000-per-brace cost. (Many clinicians/orthotists are willing to lower their prices substantially if you are paying for the brace out-of-pocket without any insurance-firm involvement.) Furthermore, you might be able to get the insurance to cover a custom-made functional brace for the left knee (given its injury history), thus leaving only the right one as an out-of-pocket expenditure. All that is needed for insurance to cover the cost of bracing is a doctor's prescription (sometimes accompanied by a letter of medical necessity).
If availability is a problem, alternatives to the Ossur CTi-Custom are either the Townsend Premier (an solid-core carbon-fibre open-frame brace which does not grip the tibial crest very well), or the Townsend Air (a carbon-fibre brace which has a full tibial shell, like the CTi-Custom; however, the Air does not have a foam core and thus is not very light). Another possibility is the Defiance from DonJoy, a lightweight hollow-core carbon-fibre brace that is very popular. But the Defiance's frame design completely avoids the tibial crest, an attribute which I consider a significant drawback (because the brace cannot grasp the shinbone, and also because the brace sits solely on the leg's soft tissues and thus moves with respect to the leg bones each time the leg muscles are tensed). All things considered, the CTi-Custom would be my first choice.
Regardless of which custom-made brace you choose, please make certain that the person fitting it is experienced specifically with the model you are purchasing.
If off-the-shelf bracing is the only option, then the CTi-OTS is fine, but keep in mind that its flexible side cuffs mean that its protection against sideways forcing is not as good as the CTi-Custom. Also suitable is the Morph from the same firm. Actually, I would prefer the Morph over the CTi-OTS because of its cleverly designed adjustable cuffs, which provide better sideways-forcing protection than the CTi-OTS. The Flex Sport would also be suitable, and would provide good protection against sideways forcing and injurious hyperextension. (In fact, the Flex Sport would probably be my first choice for off-the-shelf bracing for football.) The Townsend Rebel, an aluminum-framed brace, would not bring quite the same strength-to-weight ratio of the carbon-fibre composite that Ossur uses, but it would be entirely adequate as a prophylactic brace.
Since your son would be wearing a brace on each knee, the issue of medial-hinge protrusion comes to mind. The Ossur CTi-Custom (and in fact, all the Ossur products) have low-protrusion hinges, and so there is no concern of the braces catching on each other. The DonJoy Defiance also has a low-profile hinge design. And, Townsend's recently introduced TM5 hinge also is low-profile (although before the advent of this hinge, all of Townsend's hinges protruded too much to make them suitable for bilateral use).
If you do go the custom route, please note that the CTi-Custom is available with extra reinforcement (as are the other custom-made braces too). Such reinforcement is highly desirable for football. For any brace you purchase, make certain that it is suitable for contact sports.
One area of significant difference between the various custom-made braces mentioned above is the free-refit period. This is more of an issue in cases where the person has had surgery and there is muscle atrophy to deal with, but even for cases where the bracing is used more prophylactically (or at least, with no surgery history; I would consider the left knee has having significant lingering ligamentous damage), it is still nice to have as long a period of time during which modifications or refabrication of the bracing will be done free of charge. Ossur offers 12 months on its CTi-Custom, Townsend offers 6 on its braces, and DonJoy provides 4 months.
Meanwhile, off-the-shelf braces of course do not have free-refit periods, but usually the clinician/orthotist can make some adjustments. The Flex Sport can be heated and reshaped somewhat, the Morph can be adjusted mechanically, and aluminum-framed braces such as the Rebel can be bent to shape (taking care to keep the hinges in alignment).
All the custom-made braces mentioned earlier come with lifetime structural-mechanical warranties, which I consider especially desirable for someone pursuing football. (Currently, there are no off-the-shelf braces available with lifetime warranties.) The fact that your son is involved in a collision sport makes the extra peace of mind of lifetime-warranted bracing well worth the extra purchase cost. And, additionally, genuinely custom-made bracing provides guaranteed perfect fit, maximum strength at minimum weight, and the best possible protection against injury.
Regardless of which bracing you choose, I would be intrigued to hear of your son's experiences with it.
Yours truly,
Michael Frind.
Knee Library http://factotem.org/library
P.S.: Later this afternoon, I will be leaving for a multi-week field trip to remote northern Ontario. I expect to have some type of satellite-based internet access (hopefully satellite broadband, but I might have to make do with dial-up via satellite telephone) from the field site. I am not certain how often I will be able to visit this discussion forum, but I hope to be able to visit regularly.
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