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ROBERT E. BRYAN, BOCO, LIC.
KNEE
INSTABILITY
DISCUSSION:
FUNCTIONAL KNEE BRACING
2005
“THE
“THE ONLY
ONLY
SOURCE
SOURCE OF
OF
KNOWLEDGE
KNOWLEDGEIS
IS
EXPERIENCE”
EXPERIENCE”
ALBERT EINSTEIN
BRACING POSITION
STATEMENT A.A.O.S.
†
PROPHYLACTIC BRACING-NOT
PROVEN EFFECTIVE AND MAY
CONTRIBUTE TO INJURY
†
FUNCTIONAL BRACING-CAN BE
EFFECTIVE IN MANY TREATMENT
PROGRAMS-EFFICACY HAS BEEN
DEMONSTRATED BY SCIENTIFIC
STUDIES
KNEE BRACES
PROPHYLACTIC
FUNCTIONAL
PROPHYLACTIC KNEE
BRACING
POSITIVE DATA
†
NO
†
RE-DIRECTS FORCES
†
DIMINISHED AGILITY
THE PROPER FUNCTIONAL
BRACE DESIGN PROVIDES
†
AGILITY
†
PROTECTION
†
PROPRIOCEPTION
NON-COMPLIANT PATIENTS
WASTE VALUABLE
MEDICAL TEAM
TIME AND
RESOURCES
_____________________________
INSURANCE PROVIDER
CONCERNS
NO FUNCTIONAL BRACE
REQUIRED-NWB ACTIVITIES
RUNNERS DON’T WEAR
FUNCTIONAL KNEE BRACES
DON’T
DON’T
FORGET
FORGET
THE
THEBALL!
BALL!
GOLFERS DO!
DETERMINING FACTORS
FUNCTIONAL KNEE BRACE USAGE
†
DECISION OF HEALTH CARE TEAM AND
PATIENT
†
TYPE OF INJURY/SURGICAL REPAIR
†
PLANNED POST SURGICAL ACTIVITIES
(VOCATION/SPORTS)
†
GEOGRAPHY/DEMOGRAPHICS/POSSIBLE
LITIGATION
THE FINAL DECISION
ECONOMICS!
INSURANCE PROVIDER
ISSUES!
VANITY CONCERNS!
APPROACH WITH CAUTION
INTERNET AHEAD
THE INTERNET
KNEE BRACING SITES
CAUTION
†
493,000 KNEE BRACING SITES
†
MANUFACTURERS SITES
HUMAN ANATOMY
ORTHOTISTS
PERCEPTION
THE INTERNAL FRAME
ENDOSKELETON
‰
COMPRESSION
‰
ROTATION
‰
BLUNT FORCE
‰
AXIAL LOAD
THE HUMAN KNEE
†
†
†
†
†
†
HYDRAULIC SYSTEM
POLYCENTRIC JOINT
FRAME
FLEXORS AND EXTENDERS
SENSORS
SHOCK ABSORBER
POLYCENTRIC JOINT
CONTROLLED
†
GLIDE
†
PIVOT
†
TWIST
INSTABILITY
ANATOMICAL DEFECTS
†
†
†
†
†
†
ACL TEAR
PCL TEAR
MCL SPRAIN
PATELLAR TENDON TEAR
MENISCAL TEAR
CONDYLAR DEFECT
JOINTS
DIFFERENT ACTIONS
AGILITY
STRENGTH
THE MOST
COMPLEX
(POLYCENTRIC)
NO ROTATION OR
PIVOT
(SINGLE AXIS)
INTERNAL DERANGEMENT
SURGICAL REPAIR
EXOSKELETON
†
RUGGED DESIGN
LUNCH
†
LIMITED MOBILITY
†
VITAL SYSTEMS PROTECTED
EARLY KNEE BRACING
CONCEPTS
FLEXIBLE DESIGN / COST EFFECTIVE
THE PRESENT AND PAST
JOE NAMETH
CARBON AND
TITANIUM
LENOX HILL
DEROTATION
BRACE
STAINLESS AND
SURGICAL TUBE
FORM DICTATES FUNCTION
F
U
N
C
T
I
O
N
?
ROUND HOUSE IN GLENDORA,
NEW JERSEY
THERE ARE LIMITS
MECHANICAL AND
ANATOMICAL
FUNCTIONAL LIMITATIONS
KNEE BRACE MASS
LIMITS FLEXION
EXTENSION STOPS
LIMIT
HYPEREXTENSION
KNEE BRACING LIMITS
SOFT TISSUE CONTAINMENT
GET IT RIGHT!
† THE
FIRST TIME
†
PROPER DESIGN
†
PROPER FUNCTION
†
PROPER INSTRUCTION
“IT JUST HAPPENED”?
NOT REALLY!
†
†
†
†
†
M.O.I.
PATIENT HISTORY
MRI/X-RAY REPORTS
SURGICAL NOTES
FUTURE ACTIVITIES
EDUCATED APPROACH
BRACE TYPE AND FUNCTIONAL
DESIGN
THE BRACING PUZZLE
MIRROR
PROPRIOCEPTION
KINESTHETICS
VISUAL FEEDBACK
THE FEELING
JOINT
LOCATION
ORTHOSIS
EXTERNAL STRUCTURE
PROPRIOCEPTION
THE SENSATION OF SUPPORT AND JOINT
PLACEMENT
10 DEGREE
EXTENSION
STOP
COMBINED
INSTABILITY
STRAPPING
TIBIAL SHELL
VISUAL FEEDBACK
VISUAL FEEDBACK
MIRROR
SEEING IS
BELIEVING
THE ULTIMATE DECISION
BRACE TYPE AND FUNCTION
GAIT/JOG LAG
CONTRIBUTING FACTORS
†
EXCESSIVE BRACE
LENGTH/WEIGHT
†
IMPROPER BRACE
TYPE/FUNCTION
†
POOR FIT
PRE-MEASUREMENT DRILL
TREADMILL OR STATIONARY BIKE
A TWO MINUTE WARM-UP
TO DEFINE QUAD, HAMSTRING,
AND GASTROC MUSCULATURE
INSURES A BETTER BRACE FIT
DURING AGGRESSIVE ATHLETICS
TUNNEL VISION LIMITS
OPTIONS
THINK
OUTSIDE
THE TUBE
VARIETY OF BRACES
SOFT KNEE BRACES
†
†
†
†
†
†
†
MEDIAL
LATERAL
MCL
NON-CONTACT
PARTIAL TEAR
SPRAIN
LIMIT ROM
LOW QUALITY JOINTS
†
†
LOW COST
PRONE TO METAL FATIGUE AND
FAILURE
HINGED BRACES
SINGLE AXIS
LOW COST/QUALITY
HINGES CREATE DISTAL
BRACE MIGRATION
DURING KNEE FLEXION
NOT A POLYCENTRIC JOINT
STRUCTURAL OVERLOAD
†
JOINTS
†
FRAME MATERIAL
†
FUNCTIONAL TYPE
†
POOR QUALITY
FAILURE
ALUMINUM BRACES
†
†
†
†
†
MALLEABLE CUFFS
LIGHT WEIGHT
THIN UPRIGHTS
DURABLE
LIMITED CONTACT
OFF THE SHELF BRACING
†
BRACE FITS 90 % POPULATION
RECENTLY IMPROVED MATERIALS,
QUALITY AND FIT
MODERATE CONTACT SPORTS
COST EFFECTIVE
CUSTOM UNLOADER BRACE
FROM CAST MOLD
†
3 TO 10 DEGREES VAR/VAL
†
CONDYLAR DEFECT
†
MENISCAL REPAIR
†
MCL TEAR
SYSTEMS FAILURE
STRUCTURAL INTEGRITY COMPROMISED
ROCK
HIGH
IMPACT
SPORT SPECIFIC BRACING
CUSTOM MANUFACTURED
MUST WITHSTAND TORQUE,
HIGH IMPACT, AND
AXIAL LOADS
SPECIAL MATERIALS
AND COMPONENTS
SPORT SPECIFIC BRACING
CUSTOM BRACE FROM CAST
†
THIN JOINTS
†
INTIMATE FIT
†
CUSTOM LENGTH
†
CUSTOM STRAPPING
CUSTOM MADE BRACE
FROM CAST MOLD
†
†
TITANIUM JOINTS
CARBON FIBER SHELL
†
SUPERIOR STRAPPING
ROTATIONAL CONTROL
†
FLEXIBLE DESIGNS
†
GENDER/AGE
SPECIFIC KNEE BRACING
FEMALE
ATHLETE
ACTIVE
SENIOR
YOUNG
ADULT
CHAMELEON
RESEARCH AND
DEVELOPMENT
COLOR IT PINK,
ADD A FLOWER,
GENDER CHANGE!
GENDER SPECIFIC BRACING
†
MUST BE RUGGED
†
LESS BULK
†
SHORTER LENGTH
†
LIGHTER WEIGHT
THE YOUNGER ATHLETE
SPORTS INJURIES
LIGAMENTOUS STRAINS AND
SPRAINS
JOINT
SUBLUXATION/DISLOCATION
GROWTH PLATE INJURIES
PERFORMANCE PRESSURE
BILATERAL KNEE BRACING
†
TREAT EACH EXTREMITY
INDIVIDUALLY
†
LOW PROFILE ORTHOSIS
CONSIDER
ABILITY
AGILITY
GAIT
TOTAL CONTAINMENT
†
TRUE CUSTOM
†
FROM MOLD
†
HIGH IMPACT
†
DIMINISHED AGILITY
CUSTOM FUNCTIONAL BRACE
ADD 5 DEGREES VAR/VAL
APPLIED TO ORTHOSIS
TO OFF-LOAD MENISCAL
REPAIR, CONDYLER DEFECT
OR MCL TEAR
UNLOADING ORTHOSIS
CUSTOM
†
SINGLE JOINT
†
BULKY
†
ROTATES ON LIMB
BRACE FROM PHOTOGRAPH
†
CUSTOM COMPONENT
†
OLDER TECHNOLOGY
†
MILD
CONTACT
BRACE FROM PHOTOGRAPH
†
CUSTOM COMPONENT
†
SOFT THIGH SHELL
†
UNLOADER
†
MILD CONTACT
ANTERIOR VIEW
FLEXIBLE
THIGH
CUFF
WIDE
JOINTS
RIGID TIBIAL
SHELL
ATHLETES WHO PERFORM
MORE THAN ONE MODALITY
†
REQUIRE A MULTI-FUNCTIONAL
BRACE DESIGN
WARNING
†
FUNCTIONAL LIMITS
MANUFACTURER ETHICS
ALSO, THE BRIDGE IS
OUT!
“SALES MAN OF THE YEAR”
DOES HE UNDERSTAND?
†
BRACING CONCEPTS
†
KNEE ANATOMY
†
BRACE DESIGNS
†
EVALS AND F/U’S
EASY
STREET
“SALESMAN OF THE YEAR”
I’M
I’M THE
THE
0VER 10 BILLION SOLD
NEVER AN EVALUATION OR
FOLLOW-UP
MAN!
MAN!
BRACING CONCEPTS?
†
HEIGHT 6’ 2’
†
WEIGHT 220 LBS.
†
ACTIVITY LEVEL HIGH
†
MINIMAL CONTROL
NOT MUCH THOUGHT
BRACING CONCEPTS
NO SOFT
STRAPS OVER-
TISSUE
CONTAINMENT
SHORT CALF
COMPONENT
NO ROTATIONAL
CONTROL
TIGHTENED FOR
STABILITY
THE WRONG BRACE CHOICE
DELEGATES
POOR
PERFORMANCE
PATIENT COMPLIANCE
THE BEGINNING