12/10/2016 Plan • Brief overview of the fitting process • Case-based discussion of orthotic devices What’s the Best – Knee OA, Patella Instability, ACL (acute + reconstruction), GH Instability, and Ankle Sprain Brace for this – Cases to consider Patient? Cases • Try things on! from Sports Clinic Tim Baldwin, MA, ATC, CFo Michael Mayes, MS, ATC, CFo Dr. Anthony Luke, MD Fitting Process Fitting Process Continued • Inspect Orthosis • Instruct in don and doff • Explain purpose and objective of orthosis – Make patient don without your assistance – Advantages and Disadvantages – Make patient take a picture of the instructions – Determine expectations • Explain adjustments, potential problems, and care of orthosis • Explain the patient’s roles and responsibilities/expectations • Explain skin care • Don’t promise cures – Environmental concerns 1
12/10/2016 Case #1 Medial Meniscus Tear/Medial OA Case #1 Medial Meniscus Tear/Medial OA • 64 y.o. female who slipped on the • What type of brace might be helpful for pavement and felt a “pop” in her right this patient? knee, now has medial knee pain and • Unloader brace! mild swelling. – Unloader braces may also be used for younger • Suspicion of medial meniscus tear in patients or athletes with meniscus deficiency, setting of medial compartment OA chondral injuries or collateral ligament injuries. • Prescription for valgus unloader brace • Treat with conservative management to unload medial compartment initially – PT, Cortisone injection, activity modification, weight loss (as appropriate) consider orthotics, or bracing Case #1 Medial Meniscus Tear/Medial OA Case #1 Medial Meniscus Tear/Medial OA • Evidence supporting use of unloader brace rather • Unloader brace may also be used for chondral injuries, meniscus deficiency or MCL injuries. than neoprene sleeve? • Considerations regarding unloader braces: • Unloader braces have been shown to be more – Unicompartmental arthritis effective than neoprene sleeves for reducing pain and improving disease-specific quality of life – Lower extremity alignment (Kirkley et al.) – Patient’s body habitus – Activity goals 2
12/10/2016 Three Point Pressure System Unloader Brace Examples Townsend Breg Breg Fusion Rebel Reliever Freestyle Ossur Unloader One OA Plus • Creates valgus force to unload medial compartment Brace Pros Cons Unloader Brace Measuring & Fitting • Minimalist design • Straps cross at fibular • Most require measurement of knee circumference 6” above and Ossur • Single upright(single joint) head below patella Unloader One • Easy to use • Single upright can be – When in doubt, size up difficult if billing • Ensure full contact on condyles • Fits well on patients with • Difficult to adjust Townsend genu valgum/varum • Not much padding on Rebel • Easiest to fit when patient is seated with slight bend in knee pressure points Reliever • Have patient stand and walk with no unloading • Single upright design • Can be hot due to little • Set correction then have patient walk again Breg • Very easy to don and doff ventilation Freestyle • Easily adjusted • May stretch over time • General rule of thumb: only increase correction by .5-1 on the dial – Only increase correction every few days • Double upright • Can be uncomfortable on Breg Fusion • Easiest to use patients with prominent – Gradually increase time of use OA Plus • Cheaper tibial tuberosity 3
12/10/2016 Three Outcomes To Watch For… Case #2 Patella Maltracking/Instability • Correction feels great • 16 year old female soccer player with history of lateral patella subluxation 1 – Don’t change the dial year ago • Patient feels mild decrease of pain medially – Managed non-operatively with PT – Increase correction by .5 and see if symptoms change for 2-3 days • Athlete is concerned with aesthetics and – Continue process of “fine tuning” a brace being “too bulky” for return to • Discomfort/pain on lateral knee soccer – Could be pressure on lateral condyle or lateral meniscus – Decrease dial by .5-1 and monitor symptoms Case #2 Patella Maltracking/Instability Patella Tracking Brace Measuring and Fitting • Patella bracing has been shown to… • Most braces will require measurements 6” above and below patella – Reduce pain – Some need knee width at joint line – Decrease lateral patellar displacement • Ensure full contact on lateral edge of patella (Powers et al., Becher et al. Khadavi et al.) • Patella bracing has not been shown to prevent dislocations. • Easiest to fit with patient seated and knee fully extended • Goal of patella bracing or taping is to control excessive patella motion. 4
12/10/2016 Patellar Tracking Brace Examples Brace Pros Cons Breg PTO Soft Knee Brace DonJoy Hinged Lateral J Breg PTO • Can be most helpful in • Bulky chronic subluxations or • Little medial-Lateral acute settings support of knee • Can adjust medial pull DonJoy Lateral J • Provides pressure on • Cannot adjust medial pull patella tendon to relieve • Full skin coverage anterior knee pain Breg FreeRunner • Medial pull increases • Little medial-lateral DonJoy Reaction Web Breg FreeRunner Knee Brace DonJoy Tru-Pull Lite with knee flexion support of knee • Less bulky • Ideal for distance running Don Joy TruPull Lite • Tacky surface of lateral • Little medial-lateral buttress support of knee • Less bulky • Full skin coverage • Stretches out Case #2 Patella Maltracking/Instability DonJoy Reaction Web Brace • PROS • For this case we decided to fit for the DonJoy Reaction Web • CONS – Less bulky option – Gives an extension assist – Velcro wears down quickly during rehab – Has been shown to decrease anterior knee pain – Less rigid support – Allows skin to breathe – We have seen good results with our patients – Lacking Medial-Lateral – Contours to knee Support – Good for athletes worried about aesthetics – Allows an option for those less extreme instability cases – Can bill as a hinged knee brace 5
12/10/2016 Case #3 ACL Tear Acute Case #3 ACL Tear Acute • Patient was skiing and ski got caught, boot didn’t release, felt a pop and was • Rule out Fracture able to slowly ski down the • Knee Immobilizer for short hill term • 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 T-scope Example • One size fits nobody • Extend distal end to prevent sliding • Must pull tight • Control ROM, can lock 90-0 degrees 6
12/10/2016 Case #3 ACL Reconstruction Case #3 ACL Reconstruction • 22 year-old athlete presents 9 months after ACL reconstruction. • We have many options… • Athlete has completed a full rehab course and wants to return to – Breg playing soccer on club team – DonJoy • What goes into decision making for choosing a functional brace – Townsend for the athlete? – Ossur – 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) Brace Pros Cons Brace Pros Cons • Ideal for soccer player because • Can be slightly more • Cheaper option than most • Tibial portion can dig into of no tibial bar expensive • Easy to bill out for Medi-Cal prominent tibial tuberosity Breg • Allows room for shin guards and still get reimbursed • Can be difficult fitting on and ski boots (short tibial cuff with shin guards option) • Popular among extreme sport • Tibial portion can dig into • Least cumbersome athletes prominent tibial tuberosity DonJoy • Force Point option dampens • Includes tibial extension which • Can be difficult fitting on tendency toward can help with protection during with shin guards hyperextension in hypermobile falls athletes Ossur • Has an option to attach to ski • Donjoy a22 Lightweight but boot strong for Fast athletes • Also makes brace for surfing (Cti with AMS system) • Has option for semi- • Tibial portion can dig into Townsend customized brace prominent tibial tuberosity • Ideal for athletes with large • Can be difficult fitting on thighs and smaller calves with shin guards 7
12/10/2016 Case # 4 Glenohumeral Instability Case # 4 Glenohumeral Instability • 17 year old football player • Patient underwent short period of immobilization, full with history of first time Physical Therapy protocol, non operative treatment anterior shoulder • Recently cleared for full participation dislocation 2 months ago • Dislocation occurred in • Risk of recurrent instability? preseason game while arm tackling • Shoulder was reduced in the ED Case # 4 Glenohumeral instability Case # 4 Glenohumeral instability • Considerations regarding bracing Recurrence Related to Age – Sport and position specific risks? Age Recurrence ~20 years 94% – Timing for return to play 21-30 years 79% – Duration of treatment 31-40 years 50% • Bracing provides subjective improved stability, although no > 40 years 14% evidence of decreased rate of dislocation. (Owens et al. ) (Rowe et al.) • Counsel your patients (and parents) regarding risk of recurrence. Bracing is not always successful. 8
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