> 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.
Happy Trails Michael! I am still waiting for the artificial ligament study. When it arrives, I will post it on my website. Have a great time! PS: My son made the FB team graduating from red-shirt to MUSTANG!!! WooHoo! And his knee feels great.........
