Over my career, I certainly have seen some products developed which have drastically changed the way Athletic Trainers perform their duties. One certainly has to be the evolution of “soft cast” for splinting. While I am not sure why “soft cast” was invented initially, it certainly has had a welcomed entre’ into the Athletic Training Room.

One of my first introductions to this product was from Tony Campano, one of the best casting technique instructors I have ever had the chance to know. Tony visited me in the Athletic Training Room at South Carolina, and showed me some great techniques to be utilized with 3M Comformable Splints and also “Soft Cast” casting tape.

The primary difference in the use of “Soft Cast” and the traditional fiberglass cast tape, is the lack of underpadding required for “Soft Cast”. These casts are generally used for only a minimum of practice time (maximum of three hours) and thus do not require underpadding. Further, the product is less abrasive than the traditional fiberglass cast tape.

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Thumb Spica Using SoftCast

Back in the eighties, the Team Physician at Lenoir-Rhyne College questioned whether injuries sustained by high school football players caused more osteoarthritis. We engaged a study, to independently examine members of a local high school during their twenty-year class reunion. The subjects were examined independently by orthopaedic surgeons to determine any orthopaedic pathology which could be objectively assessed. Further, they were radiographically examined by a radiologist.

The findings were quite interesting. As one might expect, there was radiographic change merely due to the age of the subjects. However, those patients who had good medical care seemed to have less osteoarthritis. Further, patients who had undergone open surgical procedures had much more osteoarthritis than those patients treated arthroscopically.

Remember, this was about the time of the invent and advancing of the arthroscope in orthopaedics. However, the takehome message was clear – injuries were not the culprit for osteoarthritis, but possibly either the fact that grosser injury warranting open surgical intervention or the mere fact that the patient was treated with an open procedure.

The complete article is referenced below. I enjoyed working with these professionals on this article. While I learned a great deal from these peers, I probably gleaned ever more from the research and clinical process as I continued my career at other schools.

Moretz, A., Harlan, S., Goodrich, J., and Walters, R. (1984). Twenty year follow up of High School Football Injuries. The American Journal of Sports Medicine.

As an athletic trainer, I have always felt two places prophylactic braces can’t help: 1. around the ankle or 2. in the locker. Needless to say, if the brace is not comfortable, doesn’t fit, or just doesn’t feel right, the athlete is not going to wear it. I think that is one of the beautiful parts of the new functional custom-fit knee braces. They provide superior protection against knee injury as thigh and tibial cuffs have snugger, firmer fits. Donjoy has even changed the profile of the upper thigh cuff making it sleeker and conformed to the anatomicaol features of the thigh. The hinges are lower profile making the brace much sleeker than designs of the 80’s and 90’s. Braces covered athletes’ knees more tightly and provided more protection for soft tissue.

Functional Brace Use
Functional knee braces provide restraining influence to control abnormal displacements of the knee and decrease anterior tibial translation without associated contraction of the musculature of the lower extremity. With the ACL-deficient patient, brace use resulted in fewer episodes of giving way and utilization of the brace gave perception of stability in the knee.

Unilateral vs. Bilateral Hinges
When deciding on style of brace to use, Liu reported brace designs incorporating bilateral hinges and rigid shells were more effective than unilaterally hinged designs in transmitting loads8.
In the 2000 edition of Biomechanics, I reported on the comparison of knee injuries from the 1997 University of South Carolina football season when players used traditional lateral braces, vs. the 1998 season when we made the shift to custom fit knee braces that are now common. While the scope of this study is limited, the results are nonetheless very revealing as the data illustrated a substantial drop in the number and severity of knee injuries incurred. The use of the newer custom fit braces resulted in a drastic reduction in the amount of time loss (performance) by athletes as well as a drop in economical impact (medical expenses for knee injuries) for our football program.
Further studies on the subject have since supported my early findings on the ability of custom knee braces to help athletes avoid injury and the coaching and athletic training community has responded by making the use of knee braces by athletes common. In 2003, we conducted a survey to quantify prophylactic brace usage among NCAA Div I and I-AA institutions and found that over two-thirds of the institutions responding reported embracing prophylactic brace principles for their offensive lineman in their football programs. With the cost of major knee surgery averaging around $26,000, the cost of a knee brace is minimal in comparison, never mind the loss of time and eligibility by the athlete and the possible drop in performance level a major knee injury can present. In 2004, 24 of the top 25 ranked NCAA Div I football teams mandated the use of knee braces to avoid injury. This rise in popularity has not happened by accident. As an athletic trainer, I believe the increased incidence of bracing has evolved both due to increased awareness and primarily due to the superior design and construction of the braces. With research from functional knee braces following anterior cruciate ligament reconstruction, we know how the braces can minimize force production on the ligaments and further apply these concepts to functional activities in rehabilitation and activity.
I think physician and health care team members need to totally understand the concepts of prophylactic bracing when making recommendations to coaches, athletes and parents relative to this subject. Why else would these teams utilize this technology if it did not work? As I watch college football each year, the players at Florida, Ohio State, Oklahoma, Georgia, South Carolina, Florida State, Notre Dame – to name a few – have embraced prophylactic braces principles, and effectively utilized this to protect their player’s knees. Today’s discussion of prophylactic bracing is totally different that the bracing concepts discussed in the 1980’s. Those braces worn in sport were lateral braces and simply diffused the forces following lateral valgus blows to athlete’s knees. Today, the braces are functional kneed braces with double upright hinges with biomechanical design to vector force away from knee ligaments.
I have had several athletes bring their brace in to me following a practice or game and the brace is bent beyond belief, and may even be fractured! The design dissipates forces effectively and these players walked away from injuries with mild sprains. This scenario often is a heralding activity for the athlete and further substantiates brace usage. I must say, it is a sickening feeling when you examine an athlete and realize that their medical collateral ligament tear and possible anterior cruciate ligament tears which were received from a clipping injury, would have been minimized and probably prevented with prophylactic brace use as the force would have been dissipated laterally, and the double upright hinge would have also resisted the force medially. Today, coaches, parents and athletes in high school sports are realizing that spending $350 on a standard knee brace, or even $600 for a custom brace, can be a wise investment in the effort to protect young athletes from significant knee injuries – injuries that not only can hamper a promising sports career, but also adversely affect a wide range of activities and lifestyle in later years. And to do their part in supporting this trend, manufacturers are making it easier and more affordable for high school coaches and parents to outfit their athletes in prophylactic knee braces with programs such as DJO Inc’s “Join The Club” program.

The Future of Knee Bracing
The bracing industry is constantly seeking newer technologies to apply to the bracing needs. Just look at how materials which are introduced rapidly make their enterance into the industry. Further, as newer and more efficient hinges and brace composite materials evolve they product is every improved. Donjoy’s new dampening hinge has been well received in the Sports Medicine community, and is now even being fabricated in a lower brace profile. Athletes seek sleek, clean designs that work. Remember the two places braces don’t work: in the locker and around the ankle!

For some coaches and athletes the term “knee brace” conjures the unpalatable image of Joe Namath and his big, bulky Lennox Hill brace from the seventies. However, the reality is very far from that. Knee bracing in sports has rapidly evolved over the past twenty-five years with braces becoming comfortable, highly functional and commonplace in many sports – not only to help athletes return after injuries, but to protect against certain injuries in the first place. The progress that has been achieved in bracing is important for high school coaches, trainers and athletes to carefully consider.
This improved efficacy of the knee brace, particularly on a prophylactic basis, is well documented by research and very evident in the wide usage of braces among college athletes and sports programs today. As demonstrated by the studies and other data discussed below, braces today are an important and valuable piece of equipment that should be evaluated as early as the high-school level of athletics.
Back in 1984 the most common knee brace was the single hinge lateral brace used primarily in football and it was not really designed to help players avoid injuries. In fact the American Academy of Orthopaedic Surgeons didn’t even consider injury avoidance as a primary function of knee braces due to its construction and studies of the day were split on its ability to prevent injuries. Today, however, multiple studies now show that modern braces have the ability to effectively control rotational forces which produce injuries in knee ligaments. The most significant development in that evolution has been the introduction of custom fit function knee braces.

What We Find in Studies:
It is important for physicians and athletic trainers to advise athletes appropriately relative to protective equipment. Recommendations for protection require understanding of biomechanics and anatomy. Prophylactic braces were initially designed to restrain abnormal knee motions, and the knee braces have now progressed to provide functional stability.
Proper application has shown effective with the laterally applied prophylactic lateral brace as there was a decrease in valgus force application to the knee joint, often the culprit of injury to medial knee structures Physicians and athletic trainers commonly use prophylactic knee braces to protect the knee from impact forces. The principal factors that determine the impact response characteristics of a brace-knee composite are force distribution, energy absorption, and energy transmission. Material properties and the mechanical design of the brace are important factors in determining brace response to impact. The impact response can be quantified by applying lateral loads to cadaver knees and surrogate knee models. With the knee in full extension, prophylactic braces are limited in their capacity to protect the medial collateral ligament from direct lateral stress. Laboratory studies, using a surrogate knee model, concluded that preventive braces absorb 15-30% of the energy of a direct blow.

Various authors have reported on the positive effect of prophylactic bracing on the incidence and severity of knee injuries while Grace et al., and Teitz et al. reported bracing increased knee injuries. To validate the impact of prophylactic braces on this population a retrospective investigation attempted to control many of the known biases and utilized a large sample from a variety of institutions.