Jun 2, 2020Bracing For Support: Highlighting the Transformation of Braces in Athletic Rehabilitation
On the second level of the Pro Football Hall of Fame museum, just a few steps below the research and preservation observation deck resides the Lamar Hunt Super Bowl gallery — home to relics from gridiron greats on the game’s biggest stage.
Encased in glass and standing at a bent 45-degree angle sits the mostly leather knee brace that Hall of Fame quarterback Joe Namath wore as he guided the New York Jets to an infamously improbable victory over the Baltimore Colts in Super Bowl III in 1968.
As the story goes, Namath had been plagued by a right knee injury dating back to his time at the University of Alabama. Just days after signing a then-NFL record $427,000 contract as the first pick in the 1965 AFL draft, the dual-threat quarterback met with Jets team orthopedist James Nicholas to fix the injury he suffered during his senior season with the Crimson Tide. Nicholas fashioned the special brace, with the help of Lenox Hill Hospital’s brace shop, to protect Namath’s knee.
At the time, Nicholas told Namath that he might be able to only play four years in the league.
Thirteen years — and one iconic Super Bowl moment — later, Namath had pieced together a Hall of Fame-worthy career, although his knee problems would eventually worsen. And while Namath soaked up the accolades of his on-field success, the real man responsible for the quarterback’s long-term success was Nicholas — who founded the world’s first hospital-based center for the treatment and prevention of sports injuries at Lenox Hill. It is now known as the Nicholas Institute of Sports Medicine and Athletic Trauma.
That same brace, although as archaic-looking as the leather-head helmets players once adorned, was eventually worn by thousands of athletes with similar knee injuries and served as the foundation for the cutting-edge technology that athletes wear in today’s games.
Flash forward 54 years and the braces and supports athletes wear today to stay in the game have been tweaked, altered, and improved upon to not only cater to an athlete’s specific needs but are also not as nearly cumbersome as the brace Namath and his contemporaries wore.
Less Is More, More Is Better
“What’s happened over the years [was] the materials got lighter, braces became less cumbersome. The derotational braces used light-weight materials and preventative braces became derotational braces with prophylactic to protect the MCL and ACL,” Bernie DePalma, the associate director of athletics for sports medicine and head athletic trainer at Cornell University, said.
Some of the words used to describe outdated knee braces of yesteryear are cumbersome.
Clunky. Intrusive. Meddlesome. Bulky.
As DePalma, a trainer for the Big Red for 37 years, explained brace manufacturers have adopted the less is more approach — opting for light-weight materials like neoprene that give athletes better stability and mobility while providing the potential to prevent future injury.
“DonJoy started making hinge braces made of neoprene — the material that scuba diver suits are made of,” DePalma said. “And they switched to a dry-tech, moisture-wicking material that’s breathable, light-weight and simple.”
At the forefront of knee brace technology is the aforementioned DonJoy Performance and its variety of 41 different braces and sleeves. Some are designed to protect MCL. More are better equipped to support ACLs. Others cater to protecting and stabilizing the patella. There is no longer a one-brace-fits-all mentality, even when dealing with the same type of injuries. Instead more options are laid out to the athlete to find what will best tailor his or her specific situation.
For athletes, specifically offensive linemen in football, that want to protect their knees they turn to DonJoy’s Armor Fource Point. It’s a joint stabilizer for slight to severe ACL, LCL, and MCL instabilities or tears. These braces protect linemen — and even defensive players like linebackers or cornerbacks — from getting rolled up on from behind, creating a smaller probability of sustaining knee injuries in similar instances.
The DonJoy Defiance III is more an all-purpose knee brace, not only aiding athletes in contact sports but also watersports, skiing, and motocross. Its carbon fiber frame is both strong and lightweight, and its LowPro Fourcepoint Hinge technology reduces the time amount of time an athlete’s knee is in an “at-risk position” by increasing the posterior load applied by the brace on the tibia — improving the natural gait by applying progressive resistance before reaching a firm endpoint during movement. The Defiance III, in addition to many other braces on the market, is custom fabricated based on the measurements of each individual athlete and can be used for those dealing with anything from severe ACL or PCL instabilities, post-knee surgeries, MCL or LCL instabilities, and even hyperextensions.
DonJoy isn’t the only company that offers top of the line equipment to protect and stabilize athletes in the game. McDavid also has a variety of braces for the knee, ranging from sleeves, wraparound or dual-wrap braces, hinged knee braces, knee straps as well as closed and open patella braces. Sleeves often work well for mild knee paint and help with minimizing arthritis. They’re comfortable and can be worn under clothing. The wraparound or dual-wrap braces are optimal for athletes that experience mild to moderate knee pain and offer more support than sleeves.
Hinged braces are typically used post-surgery for patients and athletes who need a higher level of protection and support. For runners or athletes that participate in sports that require a lot of jumping, the knee strap helps prevent patella injuries and lowers knee pain through compression. Open and closed patella braces provide additional support to the patella tendon — with open braces allowing for relief of knee pressure and extra knee cap support with proper movement and closed braces gives compression at the knee cap with the same pressure as the rest of the knee.
“Sleeves offer comfort, compression, and warmth and in most, there’s padding in preventing contusions in elbows and knees,” DePalma said.
Other companies like Mueller, Breg, Cramer, TechWare, Powerlix, Thuasne USA/Townsend, Pro Orthopedic Devices, Ossur, ARYSE, IPOW, Shock Doctor and ProCare are also industry leaders in regards to protective and preventive knee braces and sleeves.
Tape Versus Tech
While advances in knee brace technology have grown exponentially since Nicholas fitted “Broadway Joe” with his brace en route to fulfilling his well-chronicled Super Bowl guarantee, ankle supports have teetered back-and-forth from tape to brace.
“Not a lot has changed. The ankle brace [popularity] came in waves. It was really big in the early 80’s into the late 80’s,” DePalma said. “We felt that we went back to tape in the ’90s and 2000s more so and less ankle braces.”
McDavid offers both ankle sleeves and braces that lace-up, while Mueller makes a similar-styled brace that has velcro straps.
If the choice is an ankle brace, choosing the right one comes down to what type of sport you play. For example, basketball and volleyball players may opt for braces that prevent inversion injuries where the ankle and foot turns inwards — which often leads to ankle sprains.
According to the Mayo Clinic Health System, current research indicates ankle brace use in high school-aged athletes can lower the incidence of acute ankle injuries, but not the severity. Ankle braces act as the external supports to limit certain motions, like movement at the ankle joint that points the foot downward away from the leg and turns the foot inward and provide awareness of where your ankle joint is in space.
If an athlete experiences an ankle injury like a high ankle sprain, the natural progression of support should start with a boot, then transition to a stirrup brace, followed by a normal brace and finished with tape, DePalma said, before adding that there are a variety of ways to approach it.
Opting for a brace over getting an ankle taped offers the most stability as studies have shown tape stops being supportive over time. But ultimately the choice of what brace or support to use comes down to the athlete.
Supporting The Decision
A trainer can offer guidance and suggestions to an athlete about making the right choice when it comes to deciding on wearing a specific type of brace, but the decision boils down to the athlete’s preference.
“It comes down to mostly what the athlete wants and has [those options] available,” DePalma said. “Don’t argue with the athletes.”
What leads to that decision can be a variety of factors with style and even superstition among them. Sometimes it’s the placebo effect playing a trick on the athlete’s mind that by wearing a brace they will don’t have to worry about the injury and trust the protective equipment will do its job.
At Cornell, DePalma said the trainer’s final step in the rehabilitation process is to get an athlete back on the field injury-free and without support, if necessary.
“Our goal is to have an athlete be back fully without a brace. If you want to wear a brace when they’re back playing — it’s something extra. All our rehab is geared towards having an athlete not wear [protective] gear,” DePalma said. “Once they’re seven, eight, nine months down the recovery road and getting back to playing, they’re doing all their rehab with no brace. When it comes time to doing live drills or non-contact drills they can wear it as something extra. After 12 months and back playing at a high level, it may not be needed. Offensive and defensive linemen may wear braces after the fact. But we never tell an athlete don’t wear a brace.”
So what’s the bigger reason trainers don’t force particular types of braces or that they must play without a brace post-rehabilitation? Lawsuits. According to the Journal of Athletic Training courts have recognized that a duty exists between athletic trainers and competitive athletes. The trainer’s responsibility, similar to a team physician, is to protect the health and safety of the athlete. Some of these duties include: assessing the athlete’s condition, providing or obtaining proper medical treatment, providing clearance to return to participation, and informing the athlete of the risks of athletic participation given the particular medical condition.
DePalma suggests documenting the steps in which an athlete chooses a certain brace — noting the trial period and their thoughts on the device before a final decision is made.
“That’s to protect the program, ourselves, the student and family, and by documenting that they requested it,” he said.
Another instance of a trainer providing an added layer of protection.