12/10/2016 Plan Brief overview of the fitting process Case-based - - PowerPoint PPT Presentation

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12/10/2016 Plan Brief overview of the fitting process Case-based - - PowerPoint PPT Presentation

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12/10/2016 Plan Brief overview of the fitting process Case-based discussion of orthotic devices Whats the Best Knee OA, Patella Instability, ACL (acute + reconstruction), GH Instability, and Ankle Sprain Brace for this Cases

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What’s the Best Brace for this Patient? Cases from Sports Clinic

Tim Baldwin, MA, ATC, CFo Michael Mayes, MS, ATC, CFo

  • Dr. Anthony Luke, MD

Plan

  • Brief overview of the fitting process
  • Case-based discussion of orthotic devices

– Knee OA, Patella Instability, ACL (acute + reconstruction), GH Instability, and Ankle Sprain – Cases to consider

  • Try things on!

Fitting Process

  • Inspect Orthosis
  • Explain purpose and objective of orthosis

– Advantages and Disadvantages – Determine expectations

  • Explain the patient’s roles and responsibilities/expectations
  • Don’t promise cures

Fitting Process Continued

  • Instruct in don and doff

– Make patient don without your assistance – Make patient take a picture of the instructions

  • Explain adjustments, potential problems, and care of
  • rthosis
  • Explain skin care

– Environmental concerns

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Case #1 Medial Meniscus Tear/Medial OA

  • 64 y.o. female who slipped on the

pavement and felt a “pop” in her right knee, now has medial knee pain and mild swelling.

  • Suspicion of medial meniscus tear in

setting of medial compartment OA

  • Treat with conservative management

initially

– PT, Cortisone injection, activity modification, weight loss (as appropriate) consider orthotics,

  • r bracing

Case #1 Medial Meniscus Tear/Medial OA

  • What type of brace might be helpful for

this patient?

  • Unloader brace!

– Unloader braces may also be used for younger patients or athletes with meniscus deficiency, chondral injuries or collateral ligament injuries.

  • Prescription for valgus unloader brace

to unload medial compartment

Case #1 Medial Meniscus Tear/Medial OA

  • Evidence supporting use of unloader brace rather

than neoprene sleeve?

  • Unloader braces have been shown to be more

effective than neoprene sleeves for reducing pain and improving disease-specific quality of life

(Kirkley et al.)

Case #1 Medial Meniscus Tear/Medial OA

  • Unloader brace may also be used for chondral injuries,

meniscus deficiency or MCL injuries.

  • Considerations regarding unloader braces:

– Unicompartmental arthritis – Lower extremity alignment – Patient’s body habitus – Activity goals

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Three Point Pressure System

  • Creates valgus force to unload medial compartment

Unloader Brace Examples

Ossur Unloader One Townsend Rebel Reliever Breg Freestyle Breg Fusion OA Plus Brace Pros Cons

  • Minimalist design
  • Single upright(single joint)
  • Easy to use
  • Straps cross at fibular

head

  • Single upright can be

difficult if billing

  • Fits well on patients with

genu valgum/varum

  • Difficult to adjust
  • Not much padding on

pressure points

  • Single upright design
  • Very easy to don and doff
  • Easily adjusted
  • Can be hot due to little

ventilation

  • May stretch over time
  • Double upright
  • Easiest to use
  • Cheaper
  • Can be uncomfortable on

patients with prominent tibial tuberosity Ossur Unloader One Townsend Rebel Reliever Breg Freestyle Breg Fusion OA Plus

Unloader Brace Measuring & Fitting

  • Most require measurement of knee circumference 6” above and

below patella

– When in doubt, size up

  • Ensure full contact on condyles
  • Easiest to fit when patient is seated with slight bend in knee
  • Have patient stand and walk with no unloading
  • Set correction then have patient walk again
  • General rule of thumb: only increase correction by .5-1 on the dial

– Only increase correction every few days – Gradually increase time of use

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Three Outcomes To Watch For…

  • Correction feels great

– Don’t change the dial

  • Patient feels mild decrease of pain medially

– Increase correction by .5 and see if symptoms change for 2-3 days – Continue process of “fine tuning”

  • Discomfort/pain on lateral knee

– Could be pressure on lateral condyle or lateral meniscus – Decrease dial by .5-1 and monitor symptoms

Case #2 Patella Maltracking/Instability

  • 16 year old female soccer player with

history of lateral patella subluxation 1 year ago – Managed non-operatively with PT

  • Athlete is concerned with aesthetics and

a brace being “too bulky” for return to soccer

Case #2 Patella Maltracking/Instability

  • Patella bracing has been shown to…

– Reduce pain – Decrease lateral patellar displacement

(Powers et al., Becher et al. Khadavi et al.)

  • Patella bracing has not been shown to prevent dislocations.
  • Goal of patella bracing or taping is to control excessive

patella motion.

Patella Tracking Brace Measuring and Fitting

  • Most braces will require measurements 6” above and below

patella – Some need knee width at joint line

  • Ensure full contact on lateral edge of patella
  • Easiest to fit with patient seated and knee fully extended
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Patellar Tracking Brace Examples

DonJoy Reaction Web Breg PTO Soft Knee Brace Breg FreeRunner Knee Brace DonJoy Hinged Lateral J DonJoy Tru-Pull Lite

Brace Pros Cons

Breg PTO

  • Can be most helpful in

chronic subluxations or acute settings

  • Can adjust medial pull
  • Bulky
  • Little medial-Lateral

support of knee DonJoy Lateral J

  • Provides pressure on

patella tendon to relieve anterior knee pain

  • Cannot adjust medial pull
  • Full skin coverage

Breg FreeRunner

  • Medial pull increases

with knee flexion

  • Less bulky
  • Ideal for distance running
  • Little medial-lateral

support of knee

Don Joy TruPull Lite

  • Tacky surface of lateral

buttress

  • Less bulky
  • Little medial-lateral

support of knee

  • Full skin coverage
  • Stretches out

Case #2 Patella Maltracking/Instability

  • For this case we decided to fit for the DonJoy Reaction Web

– Less bulky option – Has been shown to decrease anterior knee pain – We have seen good results with our patients

DonJoy Reaction Web Brace

  • PROS

– Gives an extension assist during rehab – Allows skin to breathe – Contours to knee – Good for athletes worried about aesthetics – Allows an option for those less extreme instability cases – Can bill as a hinged knee brace

  • CONS

– Velcro wears down quickly – Less rigid support – Lacking Medial-Lateral Support

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Case #3 ACL Tear Acute

  • Patient was skiing and ski

got caught, boot didn’t release, felt a pop and was able to slowly ski down the hill

  • 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

  • Rule out Fracture
  • Knee Immobilizer for short

term

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

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Case #3 ACL Reconstruction

  • 22 year-old athlete presents 9 months after ACL reconstruction.
  • Athlete has completed a full rehab course and wants to return to

playing soccer on club team

  • What goes into decision making for choosing a functional brace

for the athlete?

– 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-

  • peratively compared with no brace.

(Birmingham TB et al)

Case #3 ACL Reconstruction

  • We have many options…

– Breg – DonJoy – Townsend – Ossur

Brace Pros Cons

  • Cheaper option than most
  • Easy to bill out for Medi-Cal

and still get reimbursed

  • Tibial portion can dig into

prominent tibial tuberosity

  • Can be difficult fitting on

with shin guards

  • Popular among extreme sport

athletes

  • Includes tibial extension which

can help with protection during falls

  • Has an option to attach to ski

boot

  • Also makes brace for surfing

(Cti with AMS system)

  • Tibial portion can dig into

prominent tibial tuberosity

  • Can be difficult fitting on

with shin guards Breg Ossur

Brace Pros Cons

  • Ideal for soccer player because
  • f no tibial bar
  • Allows room for shin guards

and ski boots (short tibial cuff

  • ption)
  • Least cumbersome
  • Force Point option dampens

tendency toward hyperextension in hypermobile athletes

  • Donjoy a22 Lightweight but

strong for Fast athletes

  • Can be slightly more

expensive

  • Has option for semi-

customized brace

  • Ideal for athletes with large

thighs and smaller calves

  • Tibial portion can dig into

prominent tibial tuberosity

  • Can be difficult fitting on

with shin guards DonJoy Townsend

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Case # 4 Glenohumeral Instability

  • 17 year old football player

with history of first time anterior shoulder dislocation 2 months ago

  • Dislocation occurred in

preseason game while arm tackling

  • Shoulder was reduced in

the ED

Case # 4 Glenohumeral Instability

  • Patient underwent short period of immobilization, full

Physical Therapy protocol, non operative treatment

  • Recently cleared for full participation
  • Risk of recurrent instability?

Case # 4 Glenohumeral instability

  • Counsel your patients (and parents) regarding risk of
  • recurrence. Bracing is not always successful.

Recurrence Related to Age Age Recurrence ~20 years 94% 21-30 years 79% 31-40 years 50% > 40 years 14%

(Rowe et al.)

Case # 4 Glenohumeral instability

  • Considerations regarding bracing

– Sport and position specific risks? – Timing for return to play – Duration of treatment

  • Bracing provides subjective improved stability, although no

evidence of decreased rate of dislocation. (Owens et al.)

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Shoulder Bracing Examples

Sully Shoulder Stabilizer Rehband Acro Comfort Shoulder Brace Support Breg Shoulder Stabilizer

Brace Pros Cons (Never covered by

Insurance)

  • Minimalist design allows

for more overhead reach if desired

  • Used by a lot in throwing

athletes

  • Fabric stretches
  • May not prevent shoulder
  • abd. and ER as well as
  • ther features braces
  • Less restriction of

horizontal abd.

  • Minimalist design
  • Stronger fabric to resist

stretching

  • Fits left or right shoulder
  • May not resist ER
  • May shift with athletic

activity

  • Will restrict shoulder abd.

and horizontal abd.

  • Can be of benefit in

tackling sports

  • May not resist ER

Sully Shoulder Stabilizer Rehband Acro Comfort Shoulder Brace Support Breg Shoulder Stabilizer

Sawa Shoulder Stabilizer

  • Measurement of chest

circumference across nipple line

  • Designed to limit abduction and

external rotation

  • Set Abduction and ER straps at

45 degrees to keep GH head most protected

  • Brace will allow for ROM past

preset 45 degrees (Weise et al.)

  • Keep in mind that the brace may

loosen during activity and may need to be adjusted

Sawa Shoulder Stabilizer Continued

  • Main goal = restrict shoulder abduction to < 90 degrees

External Rotation Abduction

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Case #5 Grade 3 Ankle Sprain/Avulsion

  • 16 y/o male soccer

player got ankle caught in turf and inverted.

  • Unable to FWB on

ankle after injury

  • Presents with

noticeable limp, and inflammation

  • Avulsion fracture of

ATFL

Case #5 Grade 3 Ankle Sprain/Avulsion cont.

  • Athlete reports Hx of

recurrent lateral ankle sprains

  • Significant inflammatory

response

  • Significant decrease

in AROM / PROM

  • R/O high ankle

sprain/syndesmosis injury

  • XR reveals avulsion fx of

ATFL

Case #5 Grade 3 Ankle Sprain/Avulsion cont.

Device Pros Cons CAM Boot Ankle immobilization,can WB in, tall and short versions, compression Can be heavy, LLD due to height, don/doff issues Stirr-Up M/L support, compression,some can freeze for cryo No dorsi/plantarflexion control, bulky ASO Inversion/eversion, limit dorsi/plantarflexion, compression Bulky, difficult to don/doff A60 Slim design, easy don/doff, good for every day use Prevent inversion only, not as much control

Case #5 Grade 3 Ankle Sprain/Avulsion cont.

  • 4-6 Weeks

– Conservative tx w/ CAM Boot – Sized by pt's shoe size – Instruct to walk as normal as possible with boot

  • No limping

– May use crutches for NWB until pain decreases

  • 6 weeks and beyond

– Transition to ASO

  • Size to shoe size
  • Avoid pressure around styloid

process

– This is not a permanent treatment

  • Pt must cont.

with rehabilitative exercises with ATC or PT

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CAM Boot Vs. Stirr-Up

  • Syndesmotic Sprain

– Conservative tx w/ CAM Boot

  • 4-6 weeks

– Physical Therapy

  • Ankle Sprain (I-III)

– Stirr-Up*

  • Until ready to RTP

– ASO

  • When RTP
  • Not a long term solution
  • Cont. therapeutic exercises

Other Cases to Consider

  • Carpal tunnel syndrome

– Cock-up wrist splint at night

  • Mallet finger

– Stack splint

  • PCL injury

– Add posterior bump to t- scope

  • Rotator cuff injury

– Abduction sling

“Come with me and you’ll see a world of

pure imagination" – Willy Wonka

Thank you

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References

  • Amis AA, Senavongse W, Bull AM. Patellofemoral kinematics during knee flexion-extension: an

in vitro study. J Orthop Res. 2006;24(12):2201-11.

  • Becher C, Schumacher T, Fleischer B, Ettinger M, Smith T, Ostermeier S. The effects of a

dynamic patellar realignment brace on disease determinants for patellofemoral instability in the upright weight-bearing condition. J Orthop Surg Res. 2015;10:126.

  • Birmingham TB, Bryand DM, Giffin JR, Litchfield RB, Kramer JF, Donner A, Fowler PJ. A

randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. Am J Sports Med. 2008 Apr;36(4):648- 55.

  • Hart HF, Collins NJ, Ackland DC, Cowan SM, Hunt MA, Crossley KM. Immediate Effects of a

Brace on Gait Biomechanics for Predominant Lateral Knee Osteoarthritis and Valgus Malalignment After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016;44(4):865-73.

  • J. Khadavi, M. , Chen, Y. and Fredericson, M. (2015) A Novel Knee Orthosis in the Treatment of

Patellofemoral Pain Syndrome. Open Journal of Therapy and Rehabilitation, 3, 56-61. doi: 10.4236/ojtr.2015.32008.

  • Kirkley A, Webster-Bogaert S, Litchfield R, Amendola A, MacDonald S, McCalden R, Fowler P.

The effect of bracing on varus gonasrthrosis. J Bone Joint Surg Am. 1999 Apr; 81(4):539-48.

References

  • ing Active and Passive Shoulder Range of Motion in Collegiate Football Players. J Athl
  • Train. 2004;39(2):151-155.
  • Owens, BD, Dickens JF, Kilcoyne KG, Rue JP. Management of mid-season traumatic

anterior shoulder instability in athletes. J Am Acad Orthop Surg. 2012;Aug;20(8):518-26.

  • Papasoulis E, Drosos GI, Ververidis AN, Verettas DA. Functional bracing of humeral shaft
  • fractures. A review of clinical studies. Injury. 2010;41(7):e21-27.
  • Powers CM, Ward SR, Chan LD, Chen YJ, Terk MR. The effect of bracing on patella

alignment and patellofemoral joint contact area. Med Sci Sports Exerc. 2004;36(7):1226-32.

  • Rowe CR, . Acute and recurrent anterior dislocations of the shoulder. Ortho Clin North Am

1980;11:253-70.

  • Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the

treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82(4):478-86.

  • Weise K, Sitler MR, Tierney R, Swanik KA. Effectiveness of Glenohumeral-Joint Stability

Braces in Limit